Local intraosseous administration of bone forming agents and anti-resorptive agents, and devices therefor

ABSTRACT

This invention relates to local administration of a bone-forming agent and at least one anti-resorptive agent to treat osteoporosis and related disorders.

RELATED APPLICATIONS

This application is a reissue of U.S. Pat. No. 8,895,540, issued Nov.25, 2014. More than one reissue application has been filed for thereissue of U.S. Pat. No. 8,895,540. The reissue applications areapplication Ser. No. 15/357,619 (the present application), filed Nov.21, 2016; Ser. No. 15/705,553 (a divisional reissue of application Ser.No. 15/357,619), filed Sep. 15, 2017; and Ser. No. 15/705,764 (adivisional reissue of application Ser. No. 15/357,619), filed Sep. 15,2017.

BACKGROUND OF THE INVENTION

Osteoporosis is a disease that results in the weakening of bone and anincrease in the risk of fracture. It has been reported that Americanfemales over the age of 50 have about a 50% chance of breaking a boneduring their lifetime, and a 40% chance of breaking either a hip,vertebra or wrist. Post-menopausal women lose about 1-3% of their bonemass for each of the first 5-7 years after menopause. Osteoporosis isbelieved to contribute to about 1.5 million fractures a year in theUnited States, including about 700,000 spinal fractures and about300,000 hip fractures. According to the Mayo Clinic, about 25% of thepeople over 50 who fracture a hip die within a year of the incident. Therisk of breaking a bone for an osteoporotic individual doubles after thefirst fracture. The risk of breaking a second vertebra for anosteoporotic individual increases about four-fold after the first spinalfracture.

Human bone comprises hard mineralized tissue and softer collagenoustissue. The combination of these tissues provides bone with both astructural, weight-bearing capability and a shock-absorption capability.As the bone ages, however, the collagenous portion of the bone is slowlymineralized, thereby making the entire bone more brittle. To compensatefor this, bone constantly undergoes a process called “remodeling” inwhich older, more mineralized bone is replaced by new, more collagenousbone.

Bone remodeling is undertaken by two competing processes: bone formationand bone resorption. Bone formation is largely achieved by bone-formingcells called osteoblasts, while bone resorption is largely achieved bybone-eating (bone-resorbing) cells called osteoclasts. In the normaldesired situation, the rate of bone formation is essentially equal tothe rate of bone resorption, so that bone mass in the body ismaintained.

Osteoporosis occurs when the rate of bone resorption exceeds the rate ofbone formation. The rate of bone resorption is largely dependent uponthe local production of osteoclasts.

Current treatments for osteoporosis have focused upon arresting theactivity of the osteoclast cells. In particular, osteoporosis therapyhas focused upon administering drugs called “anti-resorptive agents” orARA's. The most common classes of anti-resorptive drugs includeestrogen, selective estrogen receptor modulators (SERMs),biphosphonates, calcitonin, osteoprotegrin (OPG), cathespin K andstatins. Current products include FOSAMAX® (alendronate) in the U.S.,Biphosphonate DIDRONEL® (etidronate), and ACTONEL® (risedronate).

Despite the promise provided by these anti-resorptives, there stillremain serious issues. First, many anti-resorptives act in a manner thatwholly eliminates osteoclast activity. Thus, the delicate balancebetween bone formation and bone-resorption is again upset, and older,highly mineralized tissue remains within the bone. Although this has theeffect of increasing bone mineral density (BMD), the bone that remainsis fragile and prone to microdamage.

Second, many of the anti-resorptives are administered systemically,through either oral or intravenous means. Accordingly, side effectsassociated with systemic administration are often seen. For example, thesystemic administration of hormone replacement therapy (“HRT”) has beenassociated with an elevated cancer risk. In response to this concern,some anti-resorptive drugs, such as biphosphonates, have been engineeredto be selective for bone tissue. However, in many cases, the amount ofsuch tissue selective drug that actually reaches bone is often less than100%.

In recent years, the roles of estrogen and pro-inflammatory cytokines inosteoporosis have become much more clear. For example, inpost-menopausual women, it is believed that osteoporosis occurs due to adecrease in estrogen. Because estrogen is believed to block theproduction of pro-inflammatory cytokines, a depleted level of estrogenis believed to lead to an increase in pro-inflammatory cytokines, andconsequently to increased osteoclast production and increased boneresorption.

Pacifici, R., “Cytokines, estrogen, and postmenopausal osteoporosis—thesecond decade,” Endocrinology, 139(6): 2659-2661 (1998), teaches thatestrogen prevents bone loss by blocking the production ofproinflammatory cytokines by bone marrow and bone cells. Pacificifurther discloses that IL-1 and TNF-α are the most powerfully locallyproduced stimulators of bone resorption and are well recognizedinhibitors of bone formation. Pacifici concludes that there is nowsubstantial evidence supporting the hypothesis that a network ofestrogen-regulated cytokines is responsible for the changes in boneturnover and the loss of bone induced by estrogen deficiency, and thatit is likely that during the current decade the development of orallyactive, tissue selective cytokine inhibitors will lead to new strategiesfor the prevention and treatment of postmenopausal osteoporosis. AsPacifici discloses only oral administration, Pacifici does not disclosethe local administration of selective cytokine inhibitors.

Allali, F., et al., “Increase in bone mineral density of patients withspondyloarthropathy treated with anti-tumour necrosis factor alpha,”Ann.Rheum. Dis., 62: 347-349 (2003) reports of an increase in the bonemineral density (BMD) of patients with spondyloarthropathy (SpA) treatedwith anti-tumor necrosis factor α (TNF-α). Patients in the Allali studyreceived infliximab by infusion. Allali suggests that a benefit of theanti-TNF-α therapy on BMD in patients with SpA may be through anuncoupling effect on bone cells. Allali does not disclose the localadministration of selective cytokine inhibitors.

Published U.S. Patent Application No. U.S. 2003/0007972 (“Tobinick I”)discloses methods for treating bone metastases in humans by locallyadministering a therapeutically effective dose of specific cytokineinhibitors. Tobinick discloses local administration routes designed forperilesional or intralesional use in proximity to the site of tumormetastases to bone, including subcutaneous, intramuscular, interspinous,epidural, peridural, parenteral or perispinal administration.

Tobinick, E. L., “Targeted etanercept for treatment-refractory pain dueto bone metastasis: two case reports,” Clin. Ther., 25(8): 2279-88(2003) (“Tobinick II”) discloses that etanercept delivered by targetedSC injection may be of clinical benefit in selected patients withtreatment-refractory pain caused by bone metastases.

Tobinick does not disclose the intraosseous administration of selectivecytokine inhibitors, nor does Tobinick disclose treating osteoporoticbone.

In sum, no prior art reference discloses an intraosseous injection of ahighly specific cytokine antagonist (i.e., inhibitor) inhibitor toincrease i.e., the BMD of an uncoupled resorbing bone.

Because of the limitations of anti-resorptives, some investigators havefocused on increasing bone-formation activity as a means of treatingosteoporosis. For example, teriparatide (hPTH 1-34), a fragment ofparathyroid hormone, has been found to increase the rate of boneformation and has been approved for treating osteoporosis. However, itmust be taken as a daily intravenous injection. In addition, accordingto Biskobing, D. M., “Novel therapies for osteoporosis,” Expert OpinionInvest. Drugs, 12(4): 611-621 (2003), the FDA has recommended a maximumof 2 years of treatment due to concern over long-term safety in light ofthe development of osteosarcoma in rats treated with high-doseteriparatide. See also Vahle, J. L., et al., “Skeletal changes in ratsgiven daily subcutaneous injections of recombinant human parathyroidhormone (1-34) for 2 years and relevance to human safety,” ToxicolPathol., 30(3): 312-21 (2002).

Other investigators have proposed administering selected growth factorsas a means of increasing the rate of bone formation. For example, Rodan,G. A. and Martin, T. J., “Therapeutic approaches to bone diseases,”Science, 289: 1508-1514 (2000) (“Rodan”) proposes that growth factorssuch as insulin-like growth factor (IGF), transforming growth factor-β(TGF-β) fibroblast growth factor (FGF), and bone morphogenic proteins(BMPs) have come under consideration as potential treatments for bonediseases, especially severe osteoporosis. Rodan further noted thatfuture developments might yield ways to overcome conventionaldifficulties by confining these growth factors to bone sites throughosteoblast-targeted regulation of their production, or, perhaps, by genetherapy. However, some of these growth factors may also have an effectof upregulating osteoclast activity as well.

Because of its potential as a bone growth agent, a number ofinvestigators have investigated the use of fibroblast growth factor(FGF) as a bone forming agent.

Nakamura, K., et al., “Local application of basic fibroblast growthfactor into the bone increases bone mass at the applied site inrabbits,”Arch. Orthop. Trauma Surg., 115(6): 344-346 (1996),(“Nakamura”) discloses that a single local injection of basic fibroblastgrowth factor (bFGF) into a rabbit ilium causes local bone growth.

Lane, N. E., et al., “Basic fibroblast growth factor forms newtrabeculae that physically connect with pre-existing trabeculae, andthis new bone is maintained with an anti-resorptive agent and enhancedwith an anabolic agent in an osteopenic rat model,” Osteoporosis Int'l.,14: 376-82 (2003) (“Lane”) discloses that a systemic administration ofbFGF induces bone growth in the proximal tibia of ovarectomized (“OVX”)rats. Lane further reports that the bone growth caused by the bFGFappears to resorb in these OVX rats after the administration period.Lastly, Lane reports that a post-FGF systemic administration of hPTH(1-34) was effective in maintaining the bone growth attributable to theFGF administration.

Goodman, S. et al., “Effects of local infusion of TGFbeta on boneingrowth in rabbit chambers,” J. Biomed. Mat. Res. (Appl Biomater), 53:475-479 (2000) teaches the local delivery of TGF-B in rabbit chambers.

Some investigators have advocated a combination therapy including abone-forming agent and an anti-resorptive. For example, Biskobingfurther noted that others have recommended using teriparatideconcomitantly with an anti-resorptive. Rodan, “Therapeutic approaches tobone diseases,” Science, 289: 1508-1514 (2000) concluded that far lessattention has been paid to promoting bone formation with, for example,growth factors or hormones, an approach that would be a valuable adjuncttherapy to patients receiving inhibitors of bone resorption.

U.S. Pat. No. 6,554,830 (“Chappius”) discloses a surgical anchor foranchoring within a vertebral body, having a plurality of passages forthe delivery of bone cement therethrough. Specified bone bonding cementsappear to include polymethylmethacrylate and cranial plast.

U.S. Published Patent application No. U.S. 2002/0010471 (“Wironen”)discloses methods of injecting materials into osteoporotic bones. Inparticular, Wironen is directed to a device for injecting materials intobone comprising a threaded catheter and an internal removable trocar.The subject device may also have disposed on one end an attachmentmeans, e.g., Luer-lock fitting, for attaching a syringe, whereby asyringe of any filler can then be attached to the luer-lock fitting andthe filler material can then be squirted through the catheter and intothe marrow cavity. One filler that may be used is a compositioncomprising mineralized particles (e.g., cortico-cancellous chips or“CCC” of a size from about 100 to 1000 microns, e.g., 500 to 850microns), ground bone powder (for example, from about of 100 to 1000microns, e.g., 500 to 850 microns), a biactive ceramic such as anon-degradable or degradable hydroxyapatite, bioactive glass, and thelike, osteogenic paste, chondrogenic paste, carrier associated GrowthFactors, carrier associated mineralized particles, morsellized skin orother tissue, Fibrin powder, Fibrin/plasminogen glue, Demineralized BoneMatrix (DBM)/glycerol, DBM/pleuronic F127, DBM/CCC/F127, polyesters,polyhydroxy, compounds, polyvinyl compounds, polyamino compounds,polycarbonate compounds, and mixtures of one or more of thesecompositions. Wironen further teaches that the resulting repair usingthis bone paste composition leads to a mass of mineralized tissue thatis vascularized. When non-degradable hydroxapatite is used, the mass isstable and not as subject to degradation by the osteoporotic patient.Wironen does not disclose anti-resorptive materials.

Accordingly there is a need to provide improved methods of treatment ofosteoporosis and related diseases.

SUMMARY OF THE INVENTION

The present invention provides compositions, formulations, methods anddevices for treating osteoporosis. The present inventors haveappreciated a) the desirability of providing local administration ofosteotherapeutic drugs, b) the desirability of sustaining thebone-forming activity in an osteopenic or osteoporotic bone, and c) thedesirability of restoring to pre-osteoporosis levels the bone-resorbingactivity in a bone suffering from the disease of osteoporosis.

Providing local administration of an osteotherapeutic drug is desirablebecause the local nature of the injection of the drug will significantlymitigate the risk that the drug will cause unwanted side effects outsideof the target bone. Restricting delivery to the local area also allowsthe drug to be delivered in a higher concentration than would normallybe used in a systemic administration, thereby increasing the residencetime and the potency of the therapeutic amount of the drug. In addition,without wishing to be tied to a theory, since the cortical shell of thebone comprises a relatively dense structure, this outer component of thebone may prevent the out-diffusion of the drug and so may provide asuitable depot for the osteotherapeutic drug, thereby increasing itshalf-life in the target bone.

Administering a bone-forming agent is desirable because there is aheightened risk of fracture in osteopenic or osteoporotic bone andadministration of the bone forming agent into that bone will cause newbone growth within the osteopenic or osteoporotic bone. This bone growthwill increase the strength of the bone and thereby reduce the risk ofits fracture.

Administering an anti-resorptive agent (ARA) is desirable because itwill help restore the proper and desirable balance between boneformation and bone resorption in the bone suffering from osteoporosiseven after the bone-forming agent (BFA) has been depleted. Accordingly,the bone growth provided by the BFA will be maintained indefinitely.

Accordingly, in one aspect of the present invention, the presentinventors have developed a method of therapeutically treating anuncoupled resorbing bone in a patient, comprising the steps of:

-   -   a) locally administering an effective amount of a first        formulation comprising a bone-forming agent into the bone, and    -   b) locally administering an effective amount of a second        formulation comprising an anti-resorptive agent into the bone.

The present inventors have also appreciated the many benefits ofproviding local intraosseous administration of a highly specificcytokine antagonist as an anti-resorptive agent.

First, since it is known that many cytokines (such as selectedinterleukins and TNF-α) play roles in mediating the upregulation ofosteoclast production, injecting an antagonist or inhibitor of theseproteins directly into the uncoupled resorbing bone prevents the targetcytokine from inducing any further osteoclast upregulation. In effect,the intraosseous administration of the cytokine antagonist arrests thebone resorption process of the uncoupled resorbing bone, returning it toa more coupled and balanced state. Preferably, this aspect of thepresent invention seeks to treat the uncoupled resorbing bone before itfractures.

Second, since the high specificity cytokine antagonist (HSCA) inhibitsonly the specific cytokine(s) of interest, the HSCA may be combined withother therapeutic agents (such as bone growth agents, e.g., FGF ormesenchymal stem cells) that can also be injected into the bone withoutreducing the effectiveness of those other agents.

Third, without wishing to be tied to a theory, since the cortical shellof the bone comprises a relatively dense structure, intraosseousadministration of the HSCA through this outer component of the bone mayprovide a suitable depot for the high specificity cytokine antagonist(HSCA), thereby possibly increasing its half-life in the disc.

Fourth, since it is believed that many of the problematic cytokines areactually secreted by either bone marrow or bone cells, intraosseousinjection of the high specificity antagonists will advantageously attackthe problematic cytokines at their source of origination.

Accordingly, in another aspect of the present invention, there isprovided a method of treating osteoporosis in a patient, comprisinglocally administering an effective amount of a formulation comprising aneffective amount of a highly specific cytokine antagonist into anuncoupled resorbing bone.

Accordingly, in another aspect of the present invention, there isprovided a kit for treating osteoporosis, comprising:

-   -   a) an effective amount of a bone forming agent, and    -   b) an effective amount of a highly specific cytokine antagonist.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing and other objects, features and advantages of theinvention will be apparent from the following more particulardescription of preferred embodiments of the invention, as illustrated inthe accompanying drawings in which like reference characters refer tothe same parts throughout the different views. The drawings are notnecessarily to scale, emphasis instead being placed upon illustratingthe principles of the invention.

FIG. 1 is a graph of the effect on bone tissue mass when bone resorptionexceeds bone formation, as in the case of estrogen withdrawal. H:hysterectomy.

FIG. 2 is a graph showing the transient effect of a one-time addition ofa bone forming agent to the bone of FIG. 1. H: hysterectomy. FGF:fibroblast growth factor.

FIG. 3 is a graph showing the lasting effect of the continuous presenceof an anti-resorptive agent added to the bone of FIG. 2. H:hysterectomy. FGF: fibroblast growth factor. ARA: anti-resorptive agent.

FIG. 4 is a cross-section of a human hip having a device of the presentinvention implanted therein.

FIG. 5 is a cross-section of a human hip having a device of the presentinvention implanted therein.

FIGS. 6A-F disclose some preferred administration sequences of thepresent invention. BFA: bone forming agent. ARA: anti-resorptive agent.GF: growth factor.

FIG. 7 is a cross-section of an osmotic drug pump implant of the presentinvention.

FIG. 8 is a cross-section of an osmotic drug pump implant of the presentinvention designed to deliver sequentially two drugs.

FIG. 9 is a cross-section of a modular drug delivery device of thepresent invention.

FIG. 10 is a cross-section of a modular drug delivery device of thepresent invention designed to deliver sequentially two drugs.

FIG. 11 is a cross-section of a modular drug delivery device of thepresent invention designed to deliver sequentially two drugs, which isprovided with a flexible proximal tube.

FIG. 12 is a cross-section of another embodiment of a modular drugdelivery device of the present invention.

FIG. 13 is a cross-section of an osmotic drug pump of the presentinvention designed to allow initial administration of a bone formingagent and then co-administration of anti-resorptive and bone formingagents.

FIG. 14 is a cross-section of a carrier of the present invention havingradio-opaque markers.

FIG. 15 is a cross-section of a carrier of the present invention havinga stop for preventing over-insertion of the drug pump.

FIGS. 16A-E are cross-sections of a method of using a device of thepresent invention to treat osteoporotic bone. BFA₂: second bone formingagent.

FIGS. 17A-B each disclose a lag screw of the present invention adaptedto deliver bone-forming and anti-resorptive agents to a fracture site inbone.

DETAILED DESCRIPTION OF THE INVENTION

A description of preferred embodiments of the invention follows.

For the purposes of the present invention, the terms “inhibitor” andantagonist” are used interchangeably. A protein may be inhibited at thesynthesis level, at the translation level, by shedding, by antibodies,or by soluble receptors. The term “patient” refers to a human having anuncoupled resorbing bone. A patient having “osteopenic” bone has a bonemineral density that is less than the mean bone mineral density (BMD)for that patient's age and sex. A patient having “osteoporotic” bone hasa bone mineral density that is less than two standard deviations belowthe mean for that patient's age and sex. “Local” and “intraosseous”administration are used interchangeably. A “BF agent” or “BFA” is abone-forming agent. An “AR agent” or “ARA” is an anti-resorptive agent.“OP” refers to the disease of osteoporosis.

For the purposes of the present invention “intraosseous administration”is a local administration and includes, but is not limited to:

-   -   a) injecting a formulation into the cancellous portion of an        uncoupled resorbing bone, such as a relatively intact vertebral        body,    -   b) injecting a formulation into the cortical portion of an        uncoupled resorbing bone,    -   c) providing a formulation in a patch attached to an outer wall        of the bone,    -   d) providing a formulation in a depot at a location outside but        closely closely adjacent to an outer wall of the bone,    -   e) providing the formulation in a depot at a location outside        but closely adjacent to an endplate of a vertebral body        (“trans-endplate administration”),    -   f) injecting the formulation into a local artery that        substantially empties into the target bone,    -   g) mixing the formulation with cement and injecting it into the        target area, and    -   h) delivering the formulation via metallic or non-metallic bone        fracture fixation devices/pumps to the target tissue.

Other modes of administration include parenteral, subcutaneous,intramuscular, intravenous, intraarticular, intrabronchial,intraabdominal, intracapsular, intracartilaginous, intracavitary,intracelial, intracerebellar, intracerebroventricular, intracolic,intracervical, intragastric, intrahepatic, intramyocardial, intraosteal,intrapelvic, intrapericardiac, intraperitoneal, intrapleural,intraprostatic, intrapulmonary, intrarectal, intrarenal, intraretinal,intraspinal, intrasynovial, intrathoracic, intrauterine, intravesical,bolus, vaginal, rectal, buccal, sublingual, intranasal and transdermal.In some embodiments, the ARA is administered systematically.

Because osteoporosis is a continuous process, the bone to which thetherapeutic drug is administered may be in any one of a number ofstates. In general, the bone should be characterized as uncoupledresorbing bone. For the purposes of the present invention, the boneremodeling processes in “uncoupled resorbing bone” are such that boneresorption exceeds bone formation, thereby leading to osteopenic andeventually, in some cases, osteoporotic bone. Accordingly, the bone maybe an intact bone or it may be fractured (such as a vertebral bodycompression fracture). It may be osteoporotic (defined as having a bonemineral density (BMD) of at least 2 standard deviations below normalbone mineral density for that patient's age and sex), it may beosteopenic or it may have normal bone mineral density (BMD). In someinstances, the uncoupling has existed for a time sufficient to produceosteoporotic bone. In other instances, the uncoupling has existed foronly a relatively short time and so the bone is osteopenic or normal.

In some embodiments, the target bone consists essentially of healthytissue. In other embodiments, the target bone is tumorous.

In some embodiments, the target bone is intact. In other embodiments,the target bone is fractured.

The patient may have type I osteoporosis, wherein bone resorption ratesexceed normal values, so that bone resorption exceeds bone formation. Insome embodiments thereof, the patient may be peri-menopausal. In someembodiments thereof, the patient may be post-menopausal. In eachmenopausal case, the patient is characterized as having an estrogendeficiency.

The patient may have type II osteoporosis, wherein bone formation ratesfall below normal values.

In some embodiments, the bone into which the formulation is administeredis a vertebral body. In some embodiments, the vertebral body is acervical vertebral body.

In some embodiments, the vertebral body is a thoracic vertebral body. Insome embodiments, the vertebral body is a lumbar vertebral body.

Since the vertebral body often fails by a crushing of its anteriorportion, it would be advantageous to ensure that bone growth occurs inthe anterior portion of the vertebral body. In some embodiments, theformulation is administered into the anterior half of the vertebralbody. In some embodiments, the formulation is administered into themost-anterior third of the vertebral body. In some embodiments, theformulation is administered into the most-anterior quarter of thevertebral body. In some embodiments, the formulation is administeredinto a non-fractured vertebral body and is adjacent to a fracturedvertebral body.

In conventional vertebroplasty, it has been found that the treatment ofa fractured vertebral body with high stiffness materials such aspolymethylmethacrylate (PMMA) often causes increased stress upon theintact adjacent vertebral bodies, often leading to the eventual fractureof those adjacent levels. Accordingly, in some embodiments, theformulation is administered into an intact vertebral body that isadjacent to an augmented vertebral body.

Examination of the sites of vertebral body compression fracture revealsa high prevalance of fracture at the two specific vertebrae at thethoraco-lumbar junction. In particular, the literature has reported thatfracture of either the T12 or the L1 vertebra accounts for between aboutone-third to one-half of all vertebral body compression fractures.Accordingly, in some embodiments, local intraosseous administration isprovided to a vertebra selected from the group consisting of the T12 andthe L1 vertebrae. In some embodiments, each of the T12 and the L1vertebrae are provided with local intraosseous administration.

In some embodiments, only the T12 and L1 vertebrae are provided withlocal intraosseous administration. These embodiments have the advantageof providing therapy to the two vertebra at most risk of fracture.Consequently, up to half of the vertebral body compression fracturescould be eliminated by treating only two of the 22 vertebrae present inthe human spine.

In some embodiments, each vertebra from T6 to L3 is provided withintraosseous local administration. The literature has reported thatabout 90% of all vertebral body compression fractures occur within thisregion of the spine. Consequently, about 90% of all vertebral bodycompression fractures could be eliminated by treating only about half ofthe 22 vertebrae present in the human spine.

In some embodiments, each of the vertebrae from T4 to L5 is providedwith intraosseous local administration. The literature has reported thatessentially all of the vertebral body compression fractures occur withinthis region of the spine.

In some embodiments, the bone into which the formulation is administeredis a femur. In some embodiments thereof, the formulation is administeredinto the head of the femur. In some embodiments thereof, the formulationis administered into the neck of the femur.

In some embodiments, the formulation is administered into an intact hip(i.e., hip bone). In some embodiments, the formulation is administeredinto a fractured hip. In some embodiments, the formulation isadministered into an intact hip adjacent to a fractured hip.

In some embodiments, the target tissue is a human bone selected from thegroup consisting of a foot, an ankle, a wrist (e.g., preferably, adistal radius) and a tibia (e.g., either a proximal portion or a distalportion).

In some embodiments, the formulation of the present invention isadministered directly into the bone through the outer cortical wall ofthe bone. In one embodiment, the direct administration includesdepositing the BF and/or AR agent into the cancellous portion of thebone. In this condition, the dense nature of the cortical wall thatsurrounds the cancellous portion will help keep the BF and/or AR agentcontained within the bone. In one embodiment, the direct administrationincludes depositing the BF and/or AR agent into the cortical portion ofthe bone.

FIG. 1 is a graph of the inventors' understanding of the change in bonetissue mass when bone resorption exceeds bone formation. This conditionmay occur after, for example, estrogen withdrawal. Estrogen withdrawalmay occur in women after a hysterectomy or after menopause.

As shown in the Figure, shortly after estrogen withdrawal, there is anoticeable decrease in bone tissue mass. Without wishing to be tied to atheory, it is believed that estrogen withdrawal causes an upregulationof cytokines such as TNF-α, which, in turn, causes an upregulation ofosteoclast production. The increased osteoclast production causes anuncoupling of the bone remodeling process, resulting in net bone loss.Impaired bone function is also involved. This decrease in bone functionmight be due to a decrease in local IGF-1 and/or TGF-β production.

FIG. 2 is a graph of the inventors' understanding of the change in bonetissue mass when a bone growth agent such as basic fibroblast growthfactor (bFGF) is administered after estrogen withdrawal. As shown in theFigure, the bone growth agent effectively causes bone growth to occurfor a certain period of weeks. Without wishing to be tied to a theory,it is believed that administration of the BF agent causes increased bonegrowth, thereby offsetting the increased bone resorption caused byestrogen withdrawal, resulting in net bone gain. After this short periodof weeks, however, the gradual depletion of the BF agent from the tissue(either through consumption or vascular elimination) returns the boneremodeling process to its essentially normal balanced state. After stillmore time, the continued depletion of the BF agent returns the boneremodeling process to a resorbing one resulting in continued bone loss.Simply, locally providing a bone growth agent to an osteoporotic bonemay result in only a temporary bone gain.

FIG. 3 is a graph of the inventors' understanding of the change in bonetissue mass when an anti-resorptive agent (such as an anti-TNF agent) iscontinuously administered after administration of the bone forming agenthas ceased. As shown in the Figure, the AR agent effectively maintainsthe bone growth initially provided by the bone growth agent. Withoutwishing to be tied to a theory, it is believed that continuousadministration of the AR agent at least partially inhibits theosteoclasts, thereby maintaining the bone remodeling process in aneutral state and, preferably, resulting in a net steady state bonecondition for at least as long as the AR agent is administered.

In some embodiments, at least the AR agent is provided in at leastintermittent (and more preferably, continuous) administration. Accordingto some investigators, such as Lane, the mere delivery of a BF agentwill serve to only increase bone tissue in the short term (e.g., a fewweeks). The reason for this is that, after the BF agent has beendepleted, the target bone returns to its uncoupled state and soosteoclast activity again predominates. Therefore, it is advantageous toprovide the AR agent in a plurality of administrations. In someembodiments, the administrations span at least one month. In otherembodiments, they span at least two months, for example, at least threemonths, or at least six months, or at least 12 months.

In one embodiment, at least the AR agent is provided in continuousadministration. Since bony tissue is highly vascular (and osteoporotictissue even more so), providing only intermittent administration runsthe risk that the AR agent will be depleted before the nextadministration. Therefore, it is advantageous to provide the AR agent ina continuous administration. In some embodiments, the continuousadministration spans at least one month, for example, at least twomonths, or at least three months, or at least six months, or at least 12months.

BF agent and AR agent are administered simultaneously. In others, the BFagent is administered first. In still others, the AR agent continues tobe administered after the administration of the BF agent has ceased. Insome embodiments, the AR agent is administered first.

In some embodiments, the BF agent comprises a growth factor.

In some embodiments, two BF agents are administered, for example,sequentially.

In some embodiments, the first BF is a growth factor and the second BFagent is an anabolic agent. According to Lane, supra, initialadministration of FGF results in the growth of spinculues and anincrease in trabeculae connectivity, while later administration of hPTH(1-34) increases bone mass.

In some embodiments, two growth factors are administered, for example,sequentially. In some embodiments thereof, the first BF agent is anangiogenic growth factor and the second BF agent is an osteoinductivegrowth factor. According to U.S. Pat. No. 5,270,300 (“Hunziker”), thespecification of which is incorporated herein by reference in itsentirety, the sequential administration of these agents has the benefitof first providing for neovascularization that is critical to bonegrowth. According to Hunziker, the sequential administration of thesefactors resulted in superior bone growth. Preferred angiogenic growthfactors include FGF, PDGF and TGF.

In some embodiments, three BF agents are administered, for example,sequentially.

FIG. 4 is a cross-section of a human hip having a device of the presentinvention implanted therein. FIG. 5 is a cross-section of a human hiphaving a device of the present invention implanted therein.

FIGS. 6A-F provide a number of administration scenarios considered to beuseful in treating osteoporosis.

FIG. 6A discloses a therapy comprising an initial, short-termadministration of a bone forming agent followed by a long termadministration of an AR agent. The rationale for this therapy is toinitially provide the patient with a bone forming agent to grow bone.However, since bone growth often takes only about one month to occur,the BF agent need not be administered after the first month. Thesubsequent administration of the AR agent insures that the bone grownduring the first month remains.

FIG. 6B discloses a therapy comprising an initial, short-termadministration of a growth factor followed by concomitant administrationof an AR agent and an anabolic agent. The rationale for this therapy isto initially provide the patient with newly built trabeculae-formingbridges that physically connect existing trabeculae. The subsequentadministration of the AR agent and the anabolic agent (such as hPTH1-34) respectively allows the newly grown bone to be maintained andallows additional growth to be added.

FIG. 6C discloses a therapy comprising an initial, short-termadministration of an AR agent followed by administration of a BF agent.The rationale for this therapy is to initially restore the boneremodeling balance that had been disrupted by the osteoporosis. Theadministration of a HSCA is particularly preferred in this respect.After the balance has been restored, the bone growth agent isadministered, thereby uncoupling the bone to produce bone growth.

FIG. 6D follows the initial steps of FIG. 6C, but adds a subsequentadministration of an AR agent. This therapy recognizes that, without along term administration of an AR agent, the bone formed due toadministration of the BF agent may be resorbed due to the underlyingosteoporosis.

FIG. 6E follows the rationale of FIG. 6D, but simply provides for acontinuous administration of the AR agent. This therapeutic regimen mayallow for a simpler delivery device.

FIG. 6F follows the rationale of FIG. 6E, but further provides for acontinuous administration of the AR agent. This therapeutic regimen mayallow for an even simpler delivery device, such as the device of FIG. 7.

In general, the first formulation optionally comprises an effectiveamount of a bone forming agent. The bone-forming agent may be:

-   -   a) a growth factor (such as an osteoinductive or angiogenic        factor),    -   b) osteoconductive (such as a porous matrix of granules),    -   c) osteogenic (such as viable osteoprogenitor cells), or    -   d) plasmid DNA.

In some embodiments, the formulation comprises a liquid carrier, and thebone forming agent is soluble in the carrier.

In some embodiments, the bone forming agent is a growth factor. As usedherein, the term “growth factor” encompasses any cellular product thatmodulates the growth or differentiation of other cells, particularlyconnective tissue progenitor cells. The growth factors that may be usedin accordance with the present invention include, but are not limitedto, members of the fibroblast growth factor family, including acidic andbasic fibroblast growth factor (FGF-1 and FGF-2) and FGF-4; members ofthe platelet-derived growth factor (PDGF) family, including PDGF-AB,PDGF-BB and PDGF-AA; EGFs; VEGF; members of the insulin-like growthfactor (IGF) family, including IGF-I and -II; the TGF-β superfamily,including TGF-β1, 2 and 3; osteoid-inducing factor (OIF), angiogenin(s);endothelins; hepatocyte growth factor and keratinocyte growth factor;members of the bone morphogenetic proteins (BMPs) BMP-1, BMP-3, BMP-2,OP-1, BMP-2A, BMP-2B, BMP-7 and BMP-14, including MP-52; HBGF-1 andHBGF-2; growth differentiation factors (GDFs), members of the hedgehogfamily of proteins, including indian, sonic and desert hedgehog; ADMP-1;bone-forming members of the interleukin (IL) family; GDF-5; and membersof the colony-stimulating factor (CSF) family, including CSF-1, G-CSF,and GM-CSF; and isoforms thereof.

In some embodiments, the growth factor is selected from the groupconsisting of TGF-β, bFGF, and IGF-1. These growth factors are believedto promote the regeneration of bone. In some embodiments, the growthfactor is TGF-β. More preferably, TGF-β is administered in an amount ofbetween about 10 ng/ml and about 5000 ng/ml, for example, between about50 ng/ml and about 500 ng/ml, e.g., between about 100 ng/ml and about300 ng/ml.

In some embodiments, platelet concentrate is provided as the boneforming agent. In one embodiment, the growth factors released by theplatelets are present in an amount at least two-fold (e.g., four-fold)greater than the amount found in the blood from which the platelets weretaken. In some embodiments, the platelet concentrate is autologous. Insome embodiments, the platelet concentrate is platelet rich plasma(PRP). PRP is advantageous because it contains growth factors that canrestimulate the growth of the bone, and because its fibrin matrixprovides a suitable scaffold for new tissue growth.

In some embodiments, the bone forming agent comprises an effectiveamount of a bone morphogenic protein (BMP). BMPs beneficially increasingbone formation by promoting the differentiation of mesenchymal stemcells (MSCs) into osteoblasts and their proliferation.

In some embodiments, between about 1 ng and about 10 mg of BMP areintraosseously administered into the target bone. In some embodiments,between about 1 microgram (μg) and about 1 mg of BMP are intraosseouslyadministered into the target bone.

In some embodiments, the bone forming agent comprises an effectiveamount of a fibroblast growth factor (FGF). FGF is a potent mitogen andis angiogenic, and so attracts mesenchymal stem cells to the targetarea. It is further believed that FGF stimulates osteoblasts todifferentiate into osteocytes.

In some embodiments, the FGF is acidic FGF (aFGF).

In some embodiments, the FGF is basic FGF (bFGF).

In some embodiments, between about 1 microgram (μg) and about 10,000 μgof FGF are intraosseously administered into the target bone. In someembodiments, between about 10 μg and about 1,000 μg of FGF areintraosseously administered into the target bone. In some embodiments,between about 50 μg and about 600 μg of FGF are intraosseouslyadministered into the target bone.

In some embodiments, between about 0.1 and about 4 mg/kg/day of FGF areintraosseously administered into the target bone. In some embodiments,between about 1 and about 2 mg/kg/day of FGF are intraosseouslyadministered into the target bone.

In some embodiments, FGF is intraosseously administered into the targetbone in a concentration of between about 0.1 mg/ml and about 100 mg/ml.In some embodiments, FGF is intraosseously administered into the targetbone in a concentration of between about 0.5 mg/ml and about 30 mg/ml.In some embodiments, FGF is intraosseously administered into the targetbone in a concentration of between about 1 mg/ml and about 10 mg/ml.

In some embodiments, FGF is intraosseously administered into the targetbone in an amount to provide a local tissue concentration of betweenabout 0.1 mg/kg and about 10 mg/kg.

In some embodiments, the formulation comprises a hyaluronic acid carrierand bFGF. In some embodiments, formulations described in U.S. Pat. No.5,942,499 (“Orquest”) are selected as FGF-containing formulations.

In some embodiments, the bone forming agent comprises an effectiveamount of insulin-like growth factor. IGFs beneficially increase boneformation by promoting mitogenic activity and/or cell proliferation.

In some embodiments, the bone forming agent comprises an effectiveamount of parathyroid hormone (PTH). Without wishing to be tied to atheory, it is believed that PTH beneficially increases bone formation bymediating the proliferation of osteoblasts.

In some embodiments, the PTH is a fragment or variant, such as thosetaught in U.S. Pat. No. 5,510,370 (Hock) and U.S. Pat. No. 6,590,081(Zhang), and published patent application 2002/0107200 (Chang), theentire contents of which are incorporated herein in their entirety. Inone embodiment, the PTH is PTH (1-34) (teriparatide), e.g., FORTEO® (EliLilly and Company). In some embodiments, the BFA is a parathyroidhormone derivative, such as a parathyroid hormone mutein. Examples ofparathyroid muteins are discussed in U.S. Pat. No. 5,856,138 (Fukuda),the entire contents of which are incorporated herein in its entirety.

In some embodiments, the bone forming agent comprises an effectiveamount of a statin. Without wishing to be tied to a theory, it isbelieved that statins beneficially increase bone formation by enhancingthe expression of BMPs.

In some embodiments, the bone forming agent is a porous matrix, and ispreferably injectable. In some embodiments, the porous matrix is amineral. In one embodiment, this mineral comprises calcium andphosphorus. In some embodiments, the mineral is selected from the groupconsisting of calcium phosphate, tricalcium phosphate andhydroxyapatite. In one embodiment, the average porosity of the matrix isbetween about 20 and about 500 μm, for example, between about 50 andabout 250 μm. In yet other embodiments of the present invention, in situporosity is produced in the injected matrix to produce a porous scaffoldin the injected fracture stabilizing cement. Once the in situ porosityis produced in the target tissue, the surgeon can inject othertherapeutic compounds into the porosity, thereby treating thesurrounding tissues and enhancing the remodeling process of the targettissue and the injectable cement.

In some embodiments, the mineral is administered in a granule form. Itis believed that the administration of granular minerals promotes theformation of the bone growth around the minerals such thatosteointegration occurs.

In some embodiments, the mineral is administered in a settable-pasteform. In this condition, the paste sets up in vivo, and therebyimmediately imparts post-treatment mechanical support to the fragile OPbody.

In another embodiment, the treatment is delivered via injectableabsorbable or non-absorbable cement to the target tissue. The treatmentis formulated using bioabsorbable macro-sphere technologies, such thatit will allow the release of the bone forming agent first, followed bythe release of the anti-resorptive agent. The cement will provide theinitial stability required to treat pain in fractured target tissues.These tissues include, but are not limited to, hips, knee, vertebralbody fractures and iliac crest fractures. In some embodiments, thecement is selected from the group consisting of calcium phosphate,tricalcium phosphate and hydroxyapatite. In other embodiments, thecement is any hard biocompatible cement, including PMMA, processedautogenous and allograft bone. Hydroxylapatite is a preferred cementbecause of its strength and biological profile. Tricalcium phosphate mayalso be used alone or in combination with hydroxylapatite, particularlyif some degree of resorption is desired in the cement.

In some embodiments, the porous matrix comprises a resorbable polymericmaterial.

In some embodiments, the bone forming agent comprises an injectableprecursor fluid that produces the in situ formation of a mineralizedcollagen composite. In some embodiments, the injectable precursor fluidcomprises:

-   -   a) a first formulation comprising an acid-soluble type I        collagen solution (preferably between about 1 mg/ml and about 7        mg/ml collagen) and    -   b) a second formulation comprising liposomes containing calcium        and phosphate.

Combining the acid-soluble collagen solution with the calcium- andphosphate-loaded liposomes results in a liposome/collagen precursorfluid, which, when heated from room temperature to 37° C., forms amineralized collagen gel.

In some embodiments, the liposomes are loaded withdipalmitoylphosphatidylcholine (90 mol %) and dimyristoylphosphatidylcholine (10 mol %). These liposomes are stable at roomtemperature but form calcium phosphate mineral when heated above 35° C.,a consequence of the release of entrapped salts at the lipid chainmelting transition. One such technology is disclosed in Pederson,Biomaterials 24: 4881-4890 (2003), the specification of which isincorporated herein by reference in its entirety.

Alternatively, the in situ mineralization of collagen could be achievedby an increase in temperature achieved by other types of reactionsincluding, but not limited to, chemical, enzymatic, magnetic, electric,photo- or nuclear. Suitable sources thereof include light, chemicalreaction, enzymatically controlled reaction and an electric wireembedded in the material. To further elucidate the electric wireapproach, a wire can first be embedded in the space, heated to createthe calcium deposition, and then withdrawn. In some embodiments, thiswire may be a shape memory such as nitinol that can form the shape.Alternatively, an electrically-conducting polymer can be selected as thetemperature raising element. This polymer is heated to form thecollagen, and is then subject to disintegration and resorption in situ,thereby providing space adjacent the mineralized collagen for the boneto form.

In one embodiment, the bone forming agent is a plurality of viableosteoprogenitor cells. Such viable cells, introduced into the bone, havethe capability of at least partially repairing any bone loss experiencedby the bone during the osteoporotic process. In some embodiments, thesecells are introduced into the cancellous portion of the bone andultimately produce new cancellous bone. In others, these cells areintroduced into the cortical region and produce new cortical bone.

In some embodiments, these cells are obtained from another humanindividual (allograft), while in other embodiments, the cells areobtained from the same individual (autograft). In some embodiments, thecells are taken from bone tissue, while in others, the cells are takenfrom a non-bone tissue (and may, for example, be mesenchymal stem cells,chondrocytes or fibroblasts). In others, autograft osteocytes (such asfrom the knee, hip, shoulder, finger or ear) may be used.

In one embodiment, when viable cells are selected as an additionaltherapeutic agent or substance, the viable cells comprise mesenchymalstem cells (MSCs). MSCs provide a special advantage for administrationinto an uncoupled resorbing bone because it is believed that they canmore readily survive the relatively harsh environment present in theuncoupled resorbing bone; that they have a desirable level ofplasticity; and that they have the ability to proliferate anddifferentiate into the desired cells.

In some embodiments, the mesenchymal stem cells are obtained from bonemarrow, such as autologous bone marrow. In others, the mesenchymal stemcells are obtained from adipose tissue, preferably autologous adiposetissue.

In some embodiments, the mesenchymal stem cells injected into the boneare provided in an unconcentrated form, e.g., from fresh bone marrow. Inothers, they are provided in a concentrated form. When provided inconcentrated form, they can be uncultured. Uncultured, concentrated MSCscan be readily obtained by centrifugation, filtration, orimmuno-absorption. When filtration is selected, the methods disclosed inU.S. Pat. No. 6,049,026 (“Muschler”), the specification of which isincorporated herein by reference in its entirety, can be used. In someembodiments, the matrix used to filter and concentrate the MSCs is alsoadministered into the uncoupled resorbing bone.

Therefore, in accordance with the present invention, there is provided akit for treating uncoupled resorbing bone, comprising:

-   -   a) a first formulation comprising a bone forming agent,    -   b) a second formulation comprising an anti-resorptive agent, and    -   c) a third formulation comprising viable cells.

In some embodiments, bone cells (which may be from either an allogeneicor an autologous source) or mesenchymal stem cells, may be geneticallymodified to produce an osteoinductive bone anabolic agent which could bechosen from the list of growth factors named herein. The production ofthese osteopromotive agents may lead to bone growth.

In some embodiments, the osteoconductive material comprises calcium andphosphorus. In some embodiments, the osteoconductive material compriseshydroxyapatite. In some embodiments, the osteoconductive materialcomprises collagen. In some embodiments, the osteoconductive material isin a particulate form.

In some embodiments, the second formulation comprises an HSCA. In someembodiments, it comprises a drug pump. In some embodiments, thesustained release device comprises a bioresorbable material. The kit canfurther comprise an effective amount of a growth factor. In someembodiments, each sustained release device comprises microspheres.

Recent work has shown that plasmid DNA will not elicit an inflammatoryresponse as does the use of viral vectors. Genes encoding bone(anabolic) agents such as BMP may be efficacious if injected into theuncoupled resorbing bone. In addition, overexpression of any of thegrowth factors provided herein or other agents which would limit localosteoclast activity would have positive effects on bone growth. In oneembodiment, the plasmid contains the genetic code for human TGF-β orerythropoietin (EPO).

Accordingly, in some embodiments, the additional therapeutic agent isselected from the group consisting of viable cells and plasmid DNA.

The present invention is also directed to providing estrogen to theuncoupled resorbing bone. Therefore, in some embodiments, the secondformulation comprises an effective amount of estrogen as ananti-resorptive.

These estrogen molecules serve to regulate the production ofpro-inflammatory molecules such as TNF-α and certain interleukins.

It is believed that the elimination of estrogen is the primary cause ofpost-menopausal osteoporosis. Estrogen acts through high affinityreceptors for osteoblasts and osteoclasts to regulate bone turnover.When this control is lost during menopause, bone resorption increases.Accordingly, re-establishing natural levels of estrogen in thepost-menopausal bone should help re-establish more natural levels ofosteoclasts.

Therefore, in accordance with another embodiment of the presentinvention, there is provided a method of treating OP, comprisingintraosseously administering an effective amount of a formulationcomprising estrogen into an uncoupled resorbing bone.

In some embodiments, the second formulation comprises an effectiveamount of Selective Estrogen Receptor Modulator (“SERM”). Withoutwishing to be tied to a theory, it is believed that a SERM binds withhigh affinity to estrogen receptors, but does so in a different mannerthan estrogen, and may regulate bone growth by mediating theupregulation of TGF-β.

In some embodiments, the SERM is selected from the group consisting ofraloxifene, tamoxifen and droloxifene.

Biphosphonates (BP) are useful in treating uncoupled bone because theybind to the mineral portion of bone and are taken up by the osteoclasts.Once inside the osteoclast, they inhibit an enzyme essential to bothosteoclast activity and survival.

In some embodiments, the BP is selected from the group consisting ofalendronate, clodronate, EB-1053, etidronate, ibandronate, incadronate,neridronate, olpadronate, pamidronate, risedronate, tiludronate, YH-529and zoledronate.

In some embodiments, the second formulation comprises an effectiveamount of calcitonin. Without wishing to be tied to a theory, it isbelieved that calcitonin binds to a G protein-coupled receptor in theosteoclast, and inhibits the osteoclast through both the calcium andcyclic AMP pathways.

In some embodiments, the second formulation comprises an effectiveamount of osteoprotegerin (OPG), a member of the tumor necrosis factorsuperfamily. Without wishing to be tied to a theory, it is believed thatOPG binds RANK-ligand, a protein essential for osteoclastdifferentiation and development.

In addition, anti-cathepsins may also be used in accordance with thepresent invention. It is believed that inhibition of these enzymesinhibits the breakdown of the bone tissue. Preferably, the antagonistsinhibit a cathepsin selected from the group consisting of cathepsin B,cathepsin L and cathepsin K.

In some embodiments, the second formulation comprises an effectiveamount of cathespin K inhibitor. Without wishing to be tied to a theory,it is believed that cathespin K is an enzyme considered essential forbone resorption.

It is further believed that intraosseous administration of an effectiveamount of a high specificity, anti-proliferative anti-resorptive agentin the second formulation would also help provide therapy to the patienthaving OP. It is believed that antiproliferative agents may have aneffect on inflammation by affecting inflamed tissues which would limitthe production of inflammatory cytokines. In some embodiments, the highspecificity anti-proliferative is selected from the group consisting ofa) rapamycin; b) an inhibitor of cyclin dependent kinase 9 (cdk); and c)Vitamin D analogs. In one embodiment, when rapamycin is selected, adosage producing a local tissue concentration of between about 0.5 μg/kgand about 50 μg/kg is used.

Therefore, in accordance with another embodiment of the presentinvention, there is provided a method of treating OP, comprisingintraosseously administering an effective amount of a formulationcomprising a high specificity anti-proliferative agent into an uncoupledresorbing bone.

Rapamycin is a potent inhibitor of downstream signaling of TOR (targetof Rapamycin) proteins. As such, it is responsible for coordinating thebalance between protein synthesis and protein degradation. It isbelieved that OP is propagated by a loss of balance between boneregeneration and resorption. Since TOR proteins regulate multiplemetabolic pathways, rapamycin may stabilize the balance of the cycle.Rapamycin may also directly affect the proliferation and subsequentimmune reaction of osteocytes. In one embodiment, it is provided in adose of about 0.1 μM to about 10 μM.

Cdk inhibitors may directly affect the proliferation and subsequentimmune reaction of osteocytes. Exemplary cdk inhibitors includeflavopiridol, roscovitine, and compounds disclosed in PCT PatentPublication No. WO 02/057240 (Lin), the specification of which isincorporated by reference herein in its entirety. In one embodiment, thecdk inhibitor is provided in an about 1 μM to about 10 μM dose.

In some embodiments, the Vitamin D analog is a VDR ligand, preferably 1alpha 25 dihydroxyvitamin D3, a potent anti-proliferative.

The present invention is directed to providing directly into anuncoupled resorbing bone at least one highly specific cytokineantagonist (HSCA) or inhibitor capable of specifically inhibiting acytokine (for example, a pro-inflammatory cytokine) present in the bonemicroenvironment. In one embodiment, the HSCA inhibits the action of aspecific pro-inflammatory cytokine released by bone or bone marrowcells.

In some embodiments, the antagonist is capable of specificallyinhibiting a pro-inflammatory cytokine selected from the groupconsisting of TNF-α, an interleukin (preferably, IL-1, Il-6 and IL-8),FAS, an FAS ligand, and IFN-gamma. Such specific inhibitors includethose identified on pages 5-18 of U.S. Patent Publication No. U.S.2003/0039651 (“Ol-marker”), the specification of which is incorporatedherein by reference in its entirety.

In some embodiments, the HSCA inhibits the cytokine by preventing itsproduction. In some embodiments, the HSCA inhibits the cytokine bybinding to a membrane-bound cytokine. In others, the HSCA inhibits thecytokine by binding to a solubilized, e.g. soluble, cytokine. In someembodiments, the HSCA inhibitor inhibits the cytokine by both binding tomembrane-bound cytokines and binding to solubilized cytokines. In someembodiments, the HSCA is a monoclonal antibody (“mAb”). The use of mAbsis highly desirable since they bind specifically to a certain targetprotein and essentially to no other proteins. In some embodiments, theHSCA inhibits the cytokine by binding to a natural receptor of thetarget cytokine.

In some embodiments, the HSCA inhibits the cytokine by preventing itsproduction. One example thereof is an inhibitor of p38 mitogen activatedprotein (MAP) kinase. In some embodiments, the TNF inhibitor inhibitsthe TNF by binding to membrane-bound TNF in order to prevent its releasefrom membrane. In others, the TNF inhibitor inhibits the TNF by bindingto solubilized TNF. One example thereof is etanercept. In someembodiments, the TNF inhibitor inhibits the TNF by both binding tomembrane-bound TNF and to solubilized TNF. One example thereof isREMICADE® infliximab. In some embodiments, the HSCA inhibits thecytokine (e.g., TNF-α) by binding to a natural receptor of the targetcytokine. In some embodiments, the TNF-α inhibitor is an inhibitor ofTNF-α synthesis.

In some preferred embodiments, the anti-resorptive agent is a highlyspecific antagonist of tumor necrosis factor (TNF). These antagonistsare highly preferred because the literature has shown that theiradministration into osteoporotic bone has the effect of restoring theosteoclast concentration in the bone to baseline (pre-osteoporotic)levels.

In particular, Kimble, R. B., et al., “Estrogen deficiency increases theability of stromal cells to support murine osteoclastogenesis via aninterleukin-1 and tumor necrosis factor-mediated stimulation ofmacrophage colony-stimulating factor production,” J. Biol. Chem,271(46): 18890-7 (1996), (“Kimble I”) reported that both M-CSF andosteoclast concentrations return to essentially normal levels inovariectomized rats that were administered an effective amount of anIl-1/TNF-α inhibitor. Kimble, R. B., et al., “The functional block ofTNF but not of IL-6 prevents bone loss in ovariectomized mice,” J BoneMin. Res., 12(6) 935-941 (1997), (Kimble II”) reported that osteoclastconcentrations return to essentially normal levels in ovariectomizedmice that were administered an effective amount of a TNF-α inhibitor,and further conclude that the estrogen-regulated cytokine that plays acentral role in the mechanism by which estrogen deficiency causes boneloss is not IL-6, but rather TNF.

Accordingly, since these TNF antagonists do not destroy osteoclastproduction or function, but merely have the effect of returningosteoclast levels to their normal levels, they are highly preferred.

Preferred TNF antagonists include, but are not limited to, thefollowing: etanercept (ENBREL®, Amgen); infliximab (REMICADE®, Johnsonand Johnson); D2E7, a human anti-TNF monoclonal antibody (KnollPharmaceuticals, Abbott Laboratories); CDP 571 (a humanized anti-TNFIgG4 antibody) and CDP 870 (an anti-TNF alpha humanized monoclonalantibody fragment), both from Celltech; soluble TNF receptor Type I(Amgen); pegylated soluble TNF receptor Type I (PEGs TNF-R1) (Amgen);and onercept, a recombinant TNF binding protein (r-TBP-1) (Serono).

TNF antagonists suitable for compositions, combination therapy,co-administration, devices and/or methods of the present invention(optionally further comprising at least one antibody, specified portionand/or variant thereof, of the present invention), include, but are notlimited to, a TNF chemical or protein antagonist, anti-TNF antibodies, aTNF monoclonal or polyclonal antibody or fragment, a soluble TNFreceptor (e.g., p55, p70 or p85) or fragment, fusion polypeptidesthereof, a small molecule TNF antagonist such as TNF binding protein Ior II (TBP-1 or TBP-II), nerelimonmab, REMICADE® infliximab, etanercept(ENBREL®), adalimulab (HUMIRA™), CDP-571, CDP-870, afelimomab, lenerceptand the like, antigen-binding fragments thereof, and receptor moleculeswhich bind specifically to TNF; compounds which prevent and/or inhibitTNF synthesis, TNF release or its action on target cells, such asthalidomide, tenidap, and phosphodiesterase inhibitors (e.g.pentoxifylline and rolipram); A2b adenosine receptor agonists and A2badenosine receptor enhancers; compounds which prevent and/or inhibit TNFreceptor signalling, such as mitogen activated protein (MAP) kinaseinhibitors; compounds which block and/or inhibit membrane TNF cleavage,such as metalloproteinase inhibitors; compounds which block and/orinhibit TNF activity, such as angiotensin converting enzyme (ACE)inhibitors (e.g., captopril); and compounds which block and/or inhibitTNF production and/or synthesis, such as MAP kinase inhibitors.

In one embodiment, the TNA antagonist is a cycline compound. Cyclinecompounds inhibit TNF-α in a non-specific manner. TNF-α and othersimilar bioactive substances are first produced in an inactive form andtransported to the cell membrane. Upon activation, the active part ofthe pro-TNF-α is cleaved and released. This process is called sheddingand may be initiated by one or more enzymes. These enzymes all have incommon a metal ion and are called matrix metalloproteinases (MMPs).Cycline compounds are known to bind to metal ions and will therebyinhibit the action of the MMP and subsequently the release of TNF-α andother pro-inflammatory cytokines in a non-specific manner. In someembodiments, the cycline compound is selected from the group consistingof doxycycline, lymecycline, oxicycline compound, tetracycline,minocycline, chemically modified tetracycline (CMT) and KB-R7785.

As used herein, a “tumor necrosis factor antibody,” “TNF antibody,”“TNFα antibody,” or fragment and the like decreases, blocks, inhibits,abrogates or interferes with TNFα activity in vitro, in situ and/orpreferably in vivo. For example, a suitable TNF human antibody of thepresent invention can bind TNFα and includes anti-TNF antibodies,antigen-binding fragments thereof, and specified mutants or domainsthereof that bind specifically to TNF-alpha (TNFα). A suitable TNFantibody or fragment can also decrease block, abrogate, interfere,prevent and/or inhibit TNF RNA, DNA or protein synthesis, TNF release,TNF receptor signaling, membrane TNF cleavage, TNF activity, TNFproduction and/or synthesis.

The chimeric antibody cA2 comprises the antigen binding variable regionof the high-specificity neutralizing mouse anti-human TNFα IgG1antibody, designated A2, and the constant regions of a human IgG1, kappaimmunoglobulin. The human IgG1 Fc region improves allogeneic antibodyeffector function, increases the circulating serum half-life anddecreases the immunogenicity of the antibody. The avidity and epitopespecificity of the chimeric antibody cA2 is derived from the variableregion of the murine antibody A2. In a particular embodiment, apreferred source for nucleic acids encoding the variable region of themurine antibody A2 is the A2 hybridoma cell line.

Chimeric A2 (cA2) neutralizes the cytotoxic effect of both natural andrecombinant human TNFα in a dose dependent manner. From binding assaysof chimeric antibody cA2 and recombinant human TNFα, the specificityconstant of chimeric antibody cA2 was calculated to be 1.04×10¹⁰M⁻¹.Preferred methods for determining monoclonal antibody specificity andspecificity by competitive inhibition can be found in Harlow et al.,Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press,Cold Spring Harbor, N.Y. (1988); Colligan et al., eds.; CurrentProtocols in Immunology, (NY: Greene Publishing Assoc. and WileyInterscience) (1992-2000); Kozbor et al., Immunol. Today, 4:72-79(1983); and Ausubel et al., eds. Current Protocols in Molecular Biology,(NY: Wiley Interscience) (1987-2000); and Muller, R., “Determination ofaffinity and specificity of anti-hapten antibodies by competitiveradioimmunoassay,” Meth. Enzymol., 92: 589-601 (1983), which areentirely incorporated herein by reference.

In a particular embodiment, murine monoclonal antibody A2 is produced bya cell line designated c134A. Chimeric antibody cA2 is produced by acell line designated c168A. cA2 is described in detail in U.S. Pat. No.6,284,471 (Le et al.) which is incorporated by reference herein in itsentirety.

Additional examples of monoclonal anti-TNF antibodies that can be usedin the present invention are described in the art (see, e.g., U.S. Pat.No. 5,231,024; Möller, A., et al., “Monoclonal antibodies to human tumornecrosis factor alpha: in vitro and in vivo application,” A. et al.,Cytokine 2(3): 162-169 (1990); U.S. Pat. No. 6,277,969; Rathjen et al.,International Publication No. WO 91/02078 (published Feb. 21, 1991);Rubin et al., EPO Patent Publication No. 0 218 868 (published Apr. 22,1987); Yone et al., EPO Patent Publication No. 0 288 088 (published Oct.26, 1988); Liang, C. M., et al., “Production and characterization ofmonoclonal antibodies against recombinant human tumor necrosisfactor/cachectin,” Biochem. Biophys. Res. Comm., 137: 847-854 (1986);Meager, A., et al., “Preparation and characterization of monoclonalantibodies directed against antigenic determinants of recombinant humantumour necrosis factor (rTNF),” Hybridoma, 6: 305-311 (1987); Fendly, B.M., et al., “Murine monoclonal antibodies defining neutralizing epitopeson tumor necrosis factor,” Hybridoma, 6: 359-369 (1987); Bringman, T.S., et al., “Monoclonal antibodies to human tumor necrosis factors alphaand beta: application for affinity purification, immunoassays, and asstructural probes,” Hybridoma, 6: 489-507 (1987); and Hirai, M., et al.,“Production and characterization of monoclonal antibodies to human tumornecrosis factor,” J. Immunol. Meth., 96: 57-62 (1987), which referencesare entirely incorporated herein by reference).

Preferred TNF receptor molecules useful in the present invention includethose that bind TNFα with high specificity (see, e.g., Feldmann et al.,International Publication No. WO 92/07076 (published Apr. 30, 1992);Schall, T. J. et al., “Molecular cloning and expression of a receptorfor human tumor necrosis factor,” Cell, 61: 361-370 (1990); andLoetscher, H. et al., “Molecular cloning and expression of the human 55kd tumor necrosis factor receptor,” Cell, 61: 351-359 (1990), which areentirely incorporated herein by reference) and, optionally, possess lowimmunogenicity. In particular, the 55 kDa (p55 TNF-R) and the 75 kDa(p75 TNF-R) TNF cell surface receptors are useful in the presentinvention. Truncated forms of these receptors, comprising theextracellular domains (ECD) of the receptors or functional portionsthereof (see, e.g., Corcoran, A. E. et al., “Characterization of ligandbinding by the human p55 tumour-necrosis-factor receptor. Involvement ofindividual cysteine-rich repeats,” Eur. J. Biochem., 223: 831-840(1994)), are also useful in the present invention. Truncated forms ofthe TNF receptors, comprising the ECD, have been detected in urine andserum as 30 kDa and 40 kDa TNFα inhibitory binding proteins (Engelmann,H. et al., “Two tumor necrosis factor-binding proteins purified fromhuman urine. Evidence for immunological cross-reactivity with cellsurface tumor necrosis factor receptors,” J. Biol. Chem., 265:,1531-1536 (1990)). TNF receptor multimeric molecules and TNFimmunoreceptor fusion molecules, and derivatives and fragments orportions thereof, are additional examples of TNF receptor moleculeswhich are useful in the methods and compositions of the presentinvention. The TNF receptor molecules which can be used in the inventionare characterized by their ability to treat patients for extendedperiods with good to excellent alleviation of symptoms and low toxicity.Low immunogenicity and/or high specificity, as well as other undefinedproperties, can contribute to the therapeutic results achieved.

TNF receptor multimeric molecules useful in the present invention cancomprise all or a functional portion of the ECD of two or more TNFreceptors linked via one or more polypeptide linkers or other nonpeptidelinkers, such as polyethylene glycol (PEG). The multimeric molecules canfurther comprise a signal peptide of a secreted protein to directexpression of the multimeric molecule.

TNF immunoreceptor fusion molecules useful in the methods andcompositions of the present invention can comprise at least one portionof one or more immunoglobulin molecules and all or a functional portionof one or more TNF receptors. These immunoreceptor fusion molecules canbe assembled as monomers, or hetero- or homo-multimers. Theimmunoreceptor fusion molecules can also be monovalent or multivalent.An example of such a TNF immunoreceptor fusion molecule is TNFreceptor/IgG fusion protein. TNF immunoreceptor fusion molecules andmethods for their production have been described in the art (Lesslauer,W. et al., “Recombinant soluble tumor necrosis factor receptor proteinsprotect mice from lipopolysaccharide-induced lethality,” Eur. J.Immunol, 21: 2883-2886 (1991); Ashkenazi, A., et al., “Protectionagainst endotoxic shock by a tumor necrosis factor receptorimmunoadhesin,” Proc. Natl. Acad. Sci. USA, 88: 10535-10539 (1991);Peppel, K. et al., “A tumor necrosis factor (TNF) receptor-IgG heavychain chimeric protein as a bivalent antagonist of TNF activity,” J.Exp. Med., 174: 1483-1489 (1991); Kolls, J. et al., “Prolonged andeffective blockade of tumor necrosis factor activity throughadenovirus-mediated gene transfer,” Proc. Natl. Acad. Sci. USA, 91:215-219 (1994); Butler, D. M. et al., “TNF receptor fusion proteins areeffective inhibitors of TNF-mediated cytotoxicity on human KYM-1D4rhabdomyosarcoma cells,” Cytokine, 6(6): 616-623 (1994); Baker, D. etal., “Control of established experimental allergic encephalomyelitis byinhibition of tumor necrosis factor (TNF) activity within the centralnervous system using monoclonal antibodies and TNFreceptor-immunoglobulin fusion proteins,” Eur. J. Immunol., 24:2040-2048 (1994); and Beutler et al., U.S. Pat. No. 5,447,851, each ofwhich references are entirely incorporated herein by reference). Methodsfor producing immunoreceptor fusion molecules can also be found in Caponet al., U.S. Pat. No. 5,116,964; Capon et al., U.S. Pat. No. 5,225,538;and Capon, D. J. et al., “Designing CD4 immunoadhesins for AIDStherapy,” Nature, 337: 525-531 (1989), which references are entirelyincorporated herein by reference.

A functional equivalent, derivative, fragment or region of a TNFreceptor molecule refers to a protein or peptide which comprises aportion of the TNF receptor molecule, or the portion of the TNF receptormolecule nucleic acid sequence which encodes the TNF receptor molecule,that is of sufficient size and sequences to functionally resemble a TNFreceptor molecule that can be used in the present invention (e.g., bindsTNFα with high specificity and possesses low immunogenicity). Afunctional equivalent of a TNF receptor molecule also includes amodified TNF receptor molecule that functionally resembles a TNFreceptor molecule that can be used in the present invention (e.g., bindsTNFα with high specificity and possesses low immunogenicity). Forexample, a functional equivalent of a TNF receptor molecule can containa “silent” codon or one or more amino acid substitutions, deletions oradditions (e.g., substitution of one acidic amino acid for anotheracidic amino acid; or substitution of one codon encoding the same or adifferent hydrophobic amino acid for another codon encoding ahydrophobic amino acid). See Ausubel et al., Current Protocols inMolecular Biology (NY: Greene Publishing Assoc. and Wiley-Interscience)(1987-2003).

In some embodiments, the monoclonal antibody that inhibits TNF-α isselected from the group consisting of monoclonal rodent-humanantibodies, rodent antibodies, human antibodies or any portion orportions thereof, having at least one antigen binding region of animmunoglobulin variable region, which antibody binds TNF. Preferably,this monoclonal antibody is selected from the group of compoundsdisclosed in U.S. Pat. No. 6,277,969, the specification of which isentirely incorporated herein by reference. In some embodiments,REMICADE® infliximab is delivered in a formulation having an infliximabconcentration of between about 0.4 mg/ml and about 4 mg/ml.

In some embodiments, the specific inhibitor of TNF-α is an inhibitor ofp38 MAP kinase, preferably, a small molecule inhibitor of p38 MAPkinase. The inhibition of p38 MAP kinase is believed to block productionof both TNF-α and Il-2, both of which are pro-inflammatory cytokines.The small molecule inhibitors of p38 MAP kinase are very specific &potent (˜nM). Without wishing to be tied to a theory, it is believedthat inhibition of p38 should not block TGF signaling nor TGF activity.It is further believed that p38 inhibitors may also block induction ofsome metalloproteinases, COX 2 and NO synthetase. It is further believedthat P38 inhibitors do not inhibit interleukins involved in immune cellproliferation such as IL-2.

Intraosseous administration of an effective amount of a high specificityantagonist (HSA) of p38 kinase would also help provide therapy to apatient having OP. It is believed that the p38 kinase site regulates theproduction of TNF-α, IL-1 and COX-2 enzyme.

Therefore, in accordance with another embodiment of the presentinvention, there is provided a method of treating OP, comprising locallyintraosseously administering an effective amount of a formulationcomprising a high specificity antagonist of p38 kinase into an OP bone.

Preferably, they are provided in an about 10 nM to about 10 uM dose.Some high specificity antagonists of p38 kinase are disclosed in Zhang,C., “Mitogen-activated protein (MAP) kinase regulates production oftumor necrosis factor-alpha and release of arachidonic acid in mastcells. Indications of communication between p38 and p42 MAP kinases,” J.Biol. Chem., 272(20): 13397-402 (1997); Pargellis, C., “Inhibition ofp38 MAP kinase by utilizing a novel allosteric binding site,” NatureStructural Biology, 9(4): 268-272 (2002); and Chae, H. J., “The p38mitogen-activated protein kinase pathway regulates interleukin-6synthesis in response to tumor necrosis factor in osteoblasts,” Bone,28(1): 45-53 (2001), and in U.S. Pat. No. 6,541,477 (“Goehring”) andU.S. Pat. No. 5,965,583 (“Beers”), the specifications of which areherein incorporated by reference in their entirety. Preferably, the HSAof p38 kinase is administered in a dosage to produce a local tissueconcentration of between about 5 μg/kg and about 50 μg/kg.

In some embodiments, the p38 kinase inhibitor is selected from the groupconsisting of:

-   -   a) diaryl imidizole;    -   b) N,N′-diaryl urea (developed by Bayer, Boehringer Ingelheim        and Vertex);    -   c) N,N-diaryl urea (developed by Vertex);    -   d) benzophenone (developed by Leo Pharmaceuticals);    -   e) pyrazole ketone (developed by Hoffman-LaRoche);    -   f) indole amide (developed by GlaxoSmithKline and Scios);    -   g) diamides (developed by AstraZeneca);    -   h) quinazoline (developed by GlaxoSmithKline);    -   i) pyrimido [4,5-d]pyrimidinone (developed by GlaxoSmithKline        and Hoffman LaRoche); and    -   j) pyridylamino-quinazolines (developed by Scios).

Members of this group are described, for example, in Zhang et al.,supra, Pargellis et al., supra, Chae et al., supra, Cirillo, P. F. etal., “The non-diaryl heterocycle classes of p38 MAP kinase inhibitors,”Current Topics in Medicinal Chemistry, 2: 1021-1035 (2002), Boehm et al,Exp. Opin, Ther. Patents, 10(1): 25-38 (2000), and Lee, J. C. et al.,“Inhibition of p38 MAP kinase as a therapeutic strategy,”Immunopharmacology, 47: 185-2001 (2000).

In some embodiments, the p38 kinase inhibitor is selected from the groupconsisting of SK&F 86002; SB 203580; L-167307; HEP 689; SB220025;VX-745; SU4984; RWJ 68354; ZM336372; PD098059; SB235699; and SB220025.

In some embodiments, the p38 kinase inhibitor is characterized as a1-aryl-2-pyridinyl heterocycle. In some embodiments, the1-aryl-2-pyridinyl heterocycle is selected from the group consisting of:

-   -   a) 4,5 substituted imidazole,    -   b) 1,4,5 substituted imidizole;    -   c) 2,4,5 substituted imidizole;    -   d) 1,2,4,5 substituted imidizole; and    -   e) non-imidizole 5-membered ring heterocycle.

In some embodiments, the p38 kinase inhibitor has at least 3 cyclicgroups.

In some embodiments, the p38 kinase inhibitor is selected from the groupconsisting of a molecule that is readily soluble in water and asubstantially water-insoluble molecule. In some embodiments, the highlyspecific antagonist is a p38 kinase inhibitor that is a substantiallywater-insoluble molecule. The substantially water insoluble p38inhibitor may be advantageous in that, if injected into the uncoupledresorbing bone, it will remain in the bone as a solid and will onlyslightly solubize over time, thereby providing sustained release.

In some embodiments, the HSCA is a specific antagonist (i.e., inhibitor)of an interleukin. Preferably, the target interleukin is selected fromthe group consisting IL-1, IL-2, IL-6, IL-8, IL-1β and IL-12. Preferredantagonists include, but are not limited to, Kineretg (recombinant IL1-RA, Amgen), IL1-Receptor Type 2 (Amgen) and IL-1 Trap (Regeneron).

Since it is known that many pro-inflammatory proteins play a role inosteoporosis, and that the antagonists of the present invention arehighly specific, it is further believed that injecting at least two ofthe highly specific antagonists of the present invention directly intothe bone would be even more advantageous in certain embodiments.

Therefore, in accordance with the present invention, there is provided amethod of treating an osteoporotic bone, comprising administering aformulation comprising at least two highly specific antagonists ofpro-inflammatory cytokines selected from the group consisting of TNF-α,an interleukin (preferably, IL-1, Il-6 and IL-8), FAS, an FAS ligand andIFN-gamma into the bone.

In one embodiment, at least one of the substances is an antagonist ofTNF-α. In one embodiment, the other substance is an antagonist of aninterleukin.

BFAs and ARAs of the present invention can be administered either asindividual therapeutic agents or in combination with other therapeuticagents. They can be administered alone or with a pharmaceutical carrierselected on the basis of the chosen route of administration and standardpharmaceutical practice.

The dosage administered will, of course, vary depending upon knownfactors such as the pharmacodynamic characteristics of the particularagent, and its mode and route of administration; age, health, and weightof the recipient; nature and extent of symptoms, kind of concurrenttreatment, frequency of treatment, and the effect desired. Usually adaily dosage of active ingredient can be about 0.01 to 100 milligramsper kilogram of body weight. In one embodiment, about 1.0 to 5, andpreferably about 1 to 10 milligrams per kilogram per day given individed doses 1 to 6 times a day or in sustained release form iseffective to obtain desired results.

In some embodiments, agents can be administered in a dosage of about 0.1to about 100 mg/kg, such as about 0.5, 0.9, 1.0, 1.1, 1.5, 2, 3, 4, 5,6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24,25, 26, 27, 28, 29, 30, 40, 45, 50, 60, 70, 80, 90 or 100 mg/kg, perday, on at least one of day 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31,32, 33, 34, 35, 36, 37, 38, 39, or 40, or alternatively, at least one ofweek 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19or 20, or any combination thereof, using single or divided doses ofevery 24, 12, 8, 6, 4, or 2 hours, or any combination thereof. In oneembodiment, the agents are administered three times in one month, e.g.three times in the first month.

In some embodiments, dosage forms (composition) suitable for internaladministration generally contain from about 0.1 milligram to about 500milligrams of active ingredient per unit. In these pharmaceuticalcompositions, the active ingredient will ordinarily be present in anamount of about 0.5-95% by weight based on the total weight of thecomposition.

In some embodiments, agents can be formulated as a solution, suspension,emulsion or lyophilized powder in association with a pharmaceuticallyacceptable parenteral vehicle. Examples of such vehicles are water,saline, Ringer's solution, dextrose solution, and 5% human serumalbumin. Liposomes and nonaqueous vehicles such as fixed oils can alsobe used. The vehicle or lyophilized powder can contain additives thatmaintain isotonicity (e.g., sodium chloride, mannitol) and chemicalstability (e.g., buffers and preservatives). The formulation issterilized by commonly used techniques. Suitable pharmaceutical carriersare described in the most recent edition of Remington's PharmaceuticalSciences, A. Osol, a standard reference text in this field of art.

Because osteoporosis (“OP”) involves the progressive resorption of bonein which many factors are involved, in many instances, simply providinga single dose or even a regimen over the space of a few days may not besufficient to manage the OP. Therefore, there is a need to provide along-term drug therapy treatment of OP that does not require multipleinjections. Accordingly, it is desirable for the AR and/or BF agent toremain within the bone as long as possible in a pharmaceuticallyeffective amount. The half-life of the AR and/or BF agent within thebone will depend upon many factors, including the size of the AR and/orBF agent and its charge. In general, the larger the molecular weight ofthe AR and/or BF agent, the more likely it is to remain contained by thebone.

When selecting an AR and/or BF agent with a relatively short half-life(residence time) in the bone, it would be desirable for a relativelylarge dose of the AR and/or BF agent to be administered into the bone.In this condition, the residence time of the AR and/or BF agent wouldnot cause the AR and/or BF agent to fall below therapeutically effectiveconcentrations until an extended period of time has elapsed.

When injecting formulations into the bone, it is desirable that thevolume of drug delivered be no more than about 10 ml, for example, nomore than about 5 ml, (i.e., a maximum of about 5 ml) for example,between about 1 and about 3 ml.

As noted above, continuous delivery of the AR and/or BF agent isconsidered to be highly advantageous. Accordingly, in some embodiments,at least the BF and/or AR agent is provided in a sustained release(i.e., delivery) device. The sustained release device is adapted toremain within the bone for a prolonged period and slowly release the BFand/or AR agent contained therein to the surrounding environment. Thismode of delivery allows a BF and/or AR agent to remain intherapeutically effective amounts within the bone for a prolongedperiod. One or more additional therapeutic agents can also be deliveredby a sustained delivery device.

In some embodiments, the BF and/or AR agent is predominantly releasedfrom the sustained delivery device by its diffusion through thesustained delivery device (for example, through a polymer or a porousceramic such as hydroxyapatite). In others, the BF and/or AR agent ispredominantly released from the sustained delivery device by thebiodegradation of the sustained delivery device (for example,biodegradation of a polymer or a porous ceramic such as hydroxyapatite).In others, the BF and/or AR agent is predominantly released from thesustained delivery device by convection, such as through a drug pump.

In some embodiments, the sustained release device (i.e., sustaineddelivery device) comprises a bioresorbable material whose gradualerosion causes the gradual release of the BF and/or AR agent to the boneenvironment. In some embodiments, the sustained release device comprisesa bioresorbable polymer. In one embodiment, the bioresorbable polymerhas a half-life of at least one month, for example, at least two months,e.g., at least 6 months.

In some embodiments, the sustained release device provides continuousrelease. In others, it provides intermittent release. In others, thesustained release device comprises a biosensor. Other release modes mayalso be used.

In some embodiments, the sustained delivery device comprises a pluralityof bioerodable macrospheres. In some embodiments, the BF and/or AR agentis preferably contained in a gelatin (or water or other solvent) withinthe capsule, and is released to the bone environment when the outershell of the capsule has been eroded. The device can include a pluralityof capsules having outer shells of varying thickness, so that thesequential breakdown of the outer shells provides periodic release ofthe BF and/or AR agent.

In some embodiments, the sustained delivery device comprises a plurality(e.g., at least one hundred) of water-containing chambers, each chambercontaining the BF and/or AR agent. Each chamber is defined by bilayerlipid membranes comprising synthetic duplicates of naturally occurringlipids. The release of the drug can be controlled by varying at leastone of the aqueous excipients, the lipid components, and themanufacturing parameters. In one embodiment, the formulation comprisesno more than 10% lipid. In some embodiments, the DEPOFOAM™ technology ofSkyepharma PLC (London, United Kingdom) is selected.

In some embodiments, the sustained delivery device comprises a deliverysystem disclosed in U.S. Pat. No. 5,270,300 (“Hunziker”), thespecification of which is incorporated herein by reference in itsentirety.

In some embodiments, the sustained delivery device comprises a liposomaldelivery system, such as that disclosed in WO 03/000190. Liposomes aresmall spheres whose walls are layers of lipids with water. As they form,liposomes entrap water and any water soluble solutes that are present.Because of this entrapping ability, they are useful as delivery systems.For the purposes of the present invention, a preferred embodimentincludes the use of a multilamellar vesicle, and any naturally occurringphospholipid, such as dipalmitoylphosphatidylcholine (DPPC).

A liposome may be a vesicle having at least one lipid bilayersurrounding an inner liquid phase (a lipid bilayer surrounding either aliquid core or a liquid phase dispersed between it and another lipidbilayer). The liposome may have various structures such as multilamellar(MLVs), unilamellar (ULVs) and paucilamellar (PLVs) vesicles. Theresulting structure of the liposome is dependent, in part, on the choiceof materials forming the hydrophobic phase and the manufacturingparameters, such as temperature and incubation time.

Some liposomes comprise at least one amphiphilic bilayer-formingsubstance. The therapeutic substances contained therein may be containedeither within the lipid bilayer or the hydrophilic compartments of theliposome. The amphiphilic bilayer-forming substance comprises both ahydrophilic and a lipophilic group and is capable of forming, eitheralone or in combination with other lipids, the bilayer of a liposome.The lipid can have single or multiple lipophilic side chains beingeither saturated or unsaturated in nature and branched or linear instructure. The amphiphilic bilayer-forming substance can be aphospoholipid or a ceramide.

In some embodiments, the sustained delivery device comprises theco-polymer poly-DL-lactide-co-glycolide (PLG). Preferably, theformulation is manufactured by combining the BF and/or AR agent, theco-polymer and a solvent to form a droplet, and then evaporating thesolvent to form a microsphere. The plurality of microspheres are thencombined in a biocompatible diluent. Preferably, the BF and/or AR agentis released from the co-polymer by its diffusion therethrough and by thebiodegradation of the co-polymer. In some embodiments hereof, thePROLEASE® technology of Alkermes (Cambridge, Mass.) is selected.

In some embodiments, the sustained delivery device comprises a hydrogel.Hydrogels can also be used to deliver the BF and/or AR agent in atime-release manner to the disc environment. A “hydrogel” is a substanceformed when an organic polymer (natural or synthetic) is set orsolidified to create a three-dimensional open-lattice structure thatentraps molecules of water or other solution to form a gel. Thesolidification can occur, e.g., by aggregation, coagulation, hydrophobicinteractions, or cross-linking. The hydrogels employed in this inventionrapidly solidify to keep the BF and/or AR agent at the application site,thereby eliminating undesired migration from the bone. The hydrogels arealso biocompatible, e.g., not toxic, to cells suspended in the hydrogel.

A “hydrogel-BF and/or AR agent composition” is a suspension of ahydrogel-containing desired agent. The hydrogel-BF and/or AR agentcomposition forms a uniform distribution of BF and/or AR agent with awell-defined and precisely controllable density. Moreover, the hydrogelcan support very large densities of BF and/or AR agent.

Hydrogels suitable for use in the present invention includewater-containing gels, i.e., polymers characterized by hydrophilicityand insolubility in water. See, for instance, “Hydrogels”, In ConciseEncyclopedia of Polymer Science and Engineering, Mark et al., eds.(Wiley and Sons) pp. 458-459 (1990), the disclosure of which isincorporated herein entirely by reference in its entirety. Althoughtheir use is optional in the present invention, the inclusion ofhydrogels can be highly advantageous since they tend to contribute anumber of desirable qualities. By virtue of their hydrophilic,water-containing nature, hydrogels can:

-   -   a) house viable cells, such as mesenchymal stem cells and    -   b) assist with load bearing capabilities of the bone.

In one embodiment, the hydrogel is a fine, powdery synthetic hydrogel.The hydrogel can include one or more of the following: polysaccharides,proteins, polyphosphazenes, poly(oxyethylene)-poly(oxypropylene) blockpolymers, poly(oxyethylene)-poly(oxypropylene) block polymers ofethylene diamine, poly(acrylic acids), poly(methacrylic acids),copolymers of acrylic acid and methacrylic acid, poly(vinyl acetate),and sulfonated polymers.

In general, these polymers are at least partially soluble in aqueoussolutions, e.g., water, or aqueous alcohol solutions that have chargedside groups, or a monovalent ionic salt thereof. There are many examplesof polymers with acidic side groups that can be reacted with cations,e.g., poly(phosphazenes), poly(acrylic acids), and poly(methacrylicacids). Examples of acidic groups include carboxylic acid groups,sulfonic acid groups, and halogenated (preferably fluorinated) alcoholgroups. Examples of polymers with basic side groups that can react withanions are poly(vinyl amines), poly(vinyl pyridine) and poly(vinylimidazole).

In some embodiments, the sustained delivery device includes a polymerselected from the group consisting of PLA, PGA, PCL and mixturesthereof.

When the sustained delivery vehicle is essentially a depot, preferably,the formulation of the present invention is injected into the bonethrough a small bore needle. In some embodiments, the needle has a boreof about 22 gauge or less, so that the possibilities of producing tissuedamage are mitigated. For example, the needle can have a bore of about24 gauge or a smaller bore, so that the possibilities of producingtissue damage are even further mitigated.

Accordingly, in another aspect of the present invention, there isprovided a kit for treating an osteoporotic bone, comprising:

-   -   a) a first formulation comprising a bone forming agent,    -   b) a second formulation comprising an effective amount of an        anti-resorptive agent, and    -   c) a sustained release device adapted to deliver the second        formulation into the bone.

Accordingly, in another aspect of the present invention, there isprovided a kit for treating

-   -   a) a first formulation comprising an effective amount of a        bone-forming agent,    -   b) a first sustained release device adapted to deliver the first        formulation into the bone,    -   c) a second formulation comprising an effective amount of an        anti-resorptive agent, and    -   d) a second sustained release device adapted to deliver the        second formulation into the bone.

In some embodiments, the bone forming agent is an osteoconductivematerial, an anabolic agent, a growth factor (such as BMP or FGF). Insome embodiments, the second sustained release device comprises a drugpump. In some embodiments, it comprises bioresorbable materials. Thekits can also encompass an effective amount of a growth factor.

When selecting an BF and/or AR agent with a relatively long half-life,it may be assumed that a relatively small dose of the BF and/or AR agentcan be administered into the bone. In this condition, the slow depletionof the BF and/or AR agent would not cause the BF and/or AR agent to fallbelow therapeutically effective levels in the bone until an extendedperiod of time has elapsed.

In some embodiments in which BF and/or AR agents have long half-liveswithin the bone, the dose administered can be very small.

For example, if it is believed that a BF and/or AR agent is effectivewhen present in the range of about 1-10 mg/kg or 1-10 ppm (as isbelieved to be the case for the TNF antagonist REMICADE® infliximab asan AR agent), and since the cancellous portion of a cervical vertebralbody has a volume of about 3 ml (or 3 cc or 3 g), then only about 3-30μg of the HSCA would need be administered to the bone in order toprovide a long lasting effective amount of the drug. The small amountsavailable by this route reduce the chances of deleterious side effectsof the BF and/or AR agent.

For example, suppose a clinician administered 0.3 ml of 60 mg/mlREMICADE® infliximab into a 2.7 cc bone, thereby producing an infliximabconcentration in the bone of about 6 mg/ml, or 6 parts per thousand.Without wishing to be tied to a theory, if infliximab has the samehalf-life within a bone as it does when administered systemically (i.e.,about 1 week), then the concentration of infliximab would remain aboveabout 10 ppm for about 9 weeks. Therefore, if another dose were needed,the clinician would only need to provide the second dose after about twomonths.

Therefore, in some embodiments, the BF and/or AR agent is provided in adose of less than about 1 mg, for example, a maximum of about 0.5 mg,e.g., less than about 0.5 mg, e.g., less than about 0.1 mg, e.g., lessthan about 0.01 mg, e.g., less than about 0.001 mg. The smaller amountsavailable by this route reduce the chances of deleterious side effectsof the BF and/or AR agent. Preferably, the BF and/or AR agent providedin these smaller amounts is a TNF antagonist, more preferably it isREMICADE® infliximab. In some embodiments, the formulation isadministered in an amount effective to reduce osteoclast production. Insome embodiments, the formulation is administered in an amount effectiveto maintain the bone mineral density of the target bone. In someembodiments, the formulation is administered in an amount effective toincrease the bone mineral density of the target bone.

In accordance with one aspect of the invention, the BF agent, the ARagent and an additional (e.g., third) therapeutic agent(s) are locallyadministered into the bone. More than one additional therapeutic agentcan be administered. For example, there can be fourth, fifth and sixththerapeutic agents.

In some embodiments, the BF agent, AR agent and additional therapeuticagent(s) are administered simultaneously. In others, the BF agent isadministered first. In some embodiments, the AR agent is administeredafter the BF agent has been depleted.

Examples of other (additional) therapeutic agents include, but are notlimited to: vitamins and other nutritional supplements; hormones;glycoproteins; fibronectin; peptides and proteins; carbohydrates (bothsimple and/or complex); proteoglycans; oligonucleotides (sense and/orantisense DNA and/or RNA); demineralized bone matrix; antibodies (forexample, to infectious agents, tumors, drugs or hormones); gene therapyreagents; and anti-cancer agents. Genetically altered cells and/or othercells may also be included in a matrix of this invention. If desired,substances such as pain killers and narcotics may also be admixed with apolymer for delivery and release to the bone.

In some embodiments particularly suited for cancer patients, ananti-cancer drug is locally administered.

In some embodiments particularly suited for patients having a fracture,an antibiotic is locally administered for infection control.

In some embodiments, the formulation includes a radioopaque agent sothat the injected material can be fluoroscopically monitored.

In some embodiments, the formulation comprises a suitable biocompatiblesolvent such as saline. In some embodiments, the solvent is selectedfrom the solvents disclosed in U.S. Pat. No. 6,277,969, thespecification of which is incorporated herein by reference in itsentirety. In some embodiments, the solvent is preferably selected fromthe group consisting of dimethyl sulfoxide (DMSO) and ethanol.

It would be useful for the clinician to first perform a diagnostic testin order to confirm that the targeted bone is, in fact, osteoporotic orosteopenic prior to providing the injection. This is typically donethrough a DEXA (Dual X-Ray Absorptiometer) analysis.

In some embodiments, post-delivery monitoring or tracking is used toassess bone density and growth.

It is believed that intraosseous administration of an effective amountof a high specificity antagonist of the NO synthase enzyme would alsohelp provide therapy to the patient having OP. It is believed that theNO synthase enzyme regulates the production of NO, which is known tohave pro-inflammatory effects.

Therefore, in accordance with another embodiment of the presentinvention, there is provided a method of treating OP, comprisingintraosseously administering an effective amount of a formulationcomprising a high specificity antagonist of NO synthase into anuncoupled resorbing bone.

Examples of high specificity antagonists include NO synthase areN-iminoethyl-L-lysine (L-NIL), and N^(G)-monomethyl-L-arginine.

In some embodiments, the high specificity antagonists of NO synthase maybe administered systemically.

The present invention is also directed to providing a highly specificanti-apoptosis molecule to the uncoupled resorbing bone. These moleculesserve to protect against osteocyte apoptosis. Preferred compoundsinclude EPO, erythropoetin mimetic peptides, EPO mimetibodies, IGF-I,IGF-II and caspase inhibitors.

Therefore, in accordance with another embodiment of the presentinvention, there is provided a method of treating OP, comprisingintraosseously administering an effective amount of a formulationcomprising a high specificity anti-apoptotic agent into an uncoupledresorbing bone.

In addition, non-steroidal anti-inflammatory drugs (NSAIDs) may also beselected as an additional, e.g., a second, therapeutic agent. In someembodiments, the NSAID is anabolic, and is, for example, selected fromthe group consisting of TOLMETIN™ (available from Ortho-MacNeil),SUPROL™ (available from Johnson & Johnson), and Tiaprofenic acid(available from Roussel Labs). Preferably, the anabolic NSAID isadministered in a dosage sufficient to produce an initial local tissueconcentration of between about 5 μg/kg and about 500 μg/kg. In someembodiments, the NSAID is a dual inhibitor of both the COX and LOXpathways, and is preferably TEPOXALIN™ (available from Johnson &Johnson).

As noted above, local treatment of osteoporosis requires the sustainedpresence of the anti-resorptive agent within a very vascular bonytissue. Accordingly, it appears that providing a slow, continuousrelease of the anti-resorptive into the bony tissue would insure thesustained presence of the anti-resorptive agent.

Therefore, in some embodiments, there is provided a device for providingsustained delivery of a therapeutic agent into a bone, for example, adevice comprising:

-   -   a) a chamber for housing an anti-resorptive agent,    -   b) an exit port in fluid communication with the chamber,    -   c) an effective amount of an anti-resorptive agent housed within        the chamber, and    -   d) means for expelling the anti-resorptive agent from the        chamber through the exit port.

In some embodiments, the device comprises a formulation (e.g., a firstformulation) comprising an effective amount of the anti-resorptive agenthoused within the chamber.

Now referring to FIG. 7, there is provided an osmotic pump implant 1 forproviding sustained delivery of a therapeutic agent into a bone. In thisembodiment, the osmotic pump implant comprises:

-   -   a) a tubular member 11 including a proximal end portion 13, a        distal end portion 15 and a throughbore 17,    -   b) a semi-permeable membrane 21 located in the proximal end        portion of the tubular member,    -   c) a piston 25 provided in the tubular member, defining a        proximal chamber 27 and a distal chamber 29,    -   d) an osmotic engine 31 located in the proximal chamber, and    -   e) a therapeutic drug 35 located in the distal chamber,        wherein the tubular member has an outer surface adapted to        anchor to the bone, for example, an outer surface having a        fastening means 19 (e.g., a threadform) thereon.

In some embodiments, the tubular member has an outer surface which has ahook thereon. In some embodiments, the outer surface has a porosityeffective for inducing bone growth, such as a porosity with an averagepore size of between about 20 μm and about 500 μm.

The device shown in FIG. 7 works upon the following principle. Waterinfiltrates the semi-permeable membrane and is imbibed in the osmoticengine. Upon the receipt of water, the material selected for the osmoticengine swells. Since the semi-permable membrane is fixed and the pistonis axially movable, the force produced by the swelling of the osmoticengine forces the piston to slide distally. This movement in turn forcesthe drug out the distal exit port 5. In some embodiments, designfeatures of the device are adopted from U.S. Pat. No. 5,728,396(“Peery”), the specification of which is incorporated by reference inits entirety.

In some embodiments, the therapeutic drug provided in FIG. 7 is ananti-resorptive (AR) agent. In some embodiments, the device is tailoredto provide the AR agent in an amount of at least 70% of thepredetermined therapeutic level for at least about six (6) months. Insome embodiments, the therapeutic drug provided is a bone forming agent,such as a growth factor (e.g., BMP or a FGF).

A major impediment to many osmotic engine-based delivery devices is thestart-up time. In effect, the osmotic engine must be primed before thetherapeutic drug is eluted from the distal end of the device. However,since Lane, supra, has demonstrated that the anti-resorptive agent neednot be present during the initial bone-growth process, the device neednot provide the AR agent for that initial period. Rather the device maydeliver the AR agent after a lead time of at least 15 days and stillprovide therapy.

Because the bone is a very vascular tissue (and especially so in manyosteoporotic patients), it may be that the vascularity also drains thelocally administered bone forming agent (BF agent) quickly. For example,it is reasonable to expect BF agent levels to be essentially depletedwithin about 10-15 days of their local administration. Since in the caseof many BF agents, it may be advantageous to provide an effective amountof the BF agent within the bone for a longer duration, there appears tobe a need for a device that insures the continuous presence of the BFagent for an indefinite period.

Now referring to FIG. 8, there is provided an osmotic pump implant forproviding sustained delivery of two therapeutic agents to a bone,comprising:

-   -   a) a tubular member 61 having a proximal end portion 63, a        distal end portion 65 and a throughbore 67,    -   b) a semi-permeable membrane 71 located in the proximal end        portion of the tubular member,    -   c) a distal piston 75 provided in the tubular member, defining        an intermediate chamber 77 and a distal chamber 79,    -   d) a proximal piston 81 provided in the tubular member, defining        the intermediate chamber 77 and a proximal chamber 83,    -   e) an osmotic engine 85 located in the proximal chamber,    -   f) a first therapeutic drug 91 (for example, a bone forming        agent) located in the distal chamber, and    -   g) a second therapeutic drug 95 (for example, an anti-resorptive        agent) located in the intermediate chamber.

Wherein the tubular member has an outer surface adapted to anchor to thebone, for example, an outer surface having a fastening means 97 (e.g., athreadform) thereon.

In some embodiments, the tubular member has an outer surface which has ahook thereon. In some embodiments, the outer surface has a porosityeffective for inducing bone growth, such as a porosity with an averagepore size of between about 20 μm and about 500 μm.

The principal mode of action of the device of FIG. 8 is essentiallysimilar to that of FIG. 7, except that two therapeutic agents aresequentially delivered.

In some embodiments, the distal portion of the sidewall of the tubularmember has at least one exit hole (see e.g., FIG. 8, and exit hole 99),and the distal piston is sized so that its length is less than thedistance from the distal hole and to the sidewall holes. In use, thedistal piston travels distally and pushes the BF agent out of each ofthe distal hole and the sidewall holes. Eventually, the distal pistonreaches and seats within the distal end of the chamber. However, sincethe length of the distal piston is such that it does not occlude thesidewall hole, the AR agent can still elute out of the sidewall holes.Accordingly, the proximal piston pushes the AR agent out of the sidewallholes.

Since the treatment of osteoporosis is benefited by the sequential,continuous administration of the BF agent and the AR agent, thisembodiment is advantageous because it allows for the sequential,continuous administration of the BF agent and the AR agent.

Accordingly, in another aspect of the present invention, there isprovided a kit for treating osteoporosis, comprising:

-   -   a) a bone anchor comprising:        -   i) an outer surface having at least one exit hole,        -   ii) a distal end portion having at least one entry hole, and        -   iii) a throughbore in fluid communication with the entry and            exit holes;    -   b) a first formulation comprising an effective amount of a bone        forming agent, and    -   c) a second formulation comprising an effective amount of an        anti-resorptive agent.

Although the device of FIG. 4 is useful for delivering ananti-resorptive agent for a period of at least 6 months, the requirementthat the AR agent be delivered ad infinitum requires replacement of thedevice of FIG. 4 with another device. However, it is believed thatreplacement of the device of FIG. 4 will be problematic for at least tworeasons. First, removal of the device (for example, by turning thethreadform in the opposite direction) may well damage the bonesurrounding the device. This damage may produce a loose fit between thebone and the second device when it is ultimately inserted into the bone.Second, because the device has administered a bone forming agent and ananti-resorptive agent to the bone, the threadform may have beenosteointegrated into the bone, thereby making its removal extremelydifficult.

Accordingly, there is a need for a device that allows for easy removalof the drug pump.

For example, now referring to FIG. 9, there is provided a drug deliveryimplant 101 for providing sustained delivery of a therapeutic agent to abone, comprising:

-   -   a) an osmotic pump 105 having an outer surface 107, an inner        chamber 108 and an exit port 109, and    -   b) a carrier 111 having a recess 113 for receiving the osmotic        pump and a means for fastening to bone 115.

The drug delivery implant of the present invention is advantageousbecause it allows for the intermittent removal and replacement of aspent osmotic pump without harming the surrounding bone.

In some embodiments, the osmotic pump comprises:

-   -   a) a tubular member (i.e., tube) 121 including a proximal end        portion 123, a distal end portion 125 and a throughbore 127,    -   b) a semi-permeable membrane 131 located in the proximal end        portion of the tubular member,    -   c) a piston 135 provided in the tubular member, defining a        proximal chamber 137 and a distal chamber 139,    -   d) an osmotic engine 141 located in the proximal chamber, and    -   e) a therapeutic drug 143 located in the distal chamber.

In some embodiments, the carrier 111 comprises a tubular membercomprising:

-   -   i) proximal end portion 151,    -   ii) a distal end portion 153 and    -   iii) a throughbore 155 defining an inner surface 159,        wherein the outer surface has a threadform 115 thereon and the        inner surface is adapted for releasable engagement of the outer        surface of the osmotic pump.

In some embodiments, the implant comprises a throughbore in fluidcommunication with the exit port. In some embodiments, the drug pumpcomprises an osmotic engine disposed within the throughbore. In someembodiments, the drug pump contains a formulation (e.g., a firstformulation) comprising an effective amount of a bone-forming agentand/or an anti-resorptive agent. In some embodiments, the drug pumpcomprises a cylindrical outer surface, the carrier has a throughbore andthe cylindrical outer surface is adapted to fit within the throughbore.

In use, the device is implanted into the bone and the first osmotic pumpis actuated and provides therapeutic amounts of drug to the patient.After the first osmotic pump is spent, it is removed and replaced by asecond fresh osmotic pump. This process can be continued indefinitely.

In some spinal fields, problematic intervertebral discs are oftenremoved and replaced with either a fusion cage or a motion disc. In eachcase, one benefit of the implant is the restoration of disc heightbetween adjacent vertebrae lost during degeneration of the disc.However, osteoporotic patients who are otherwise candidates forprosthetic disc or fusion cage replacement may be excluded from thesesurgeries due to concerns that the severity of the osteoporosis maycause the natural endplates adjacent the problematic intervertebral discto subside into the implant, thereby decreasing the height of the discspace.

Accordingly, in one aspect of the present invention, the device of thepresent invention is inserted into at least one (and preferably both) ofthe osteoporotic vertebral bodies adjacent to the intervertebral disctargeted for replacement.

Therefore, in accordance with the present invention, there is provided amethod of treating an osteoporotic patient, comprising the steps of:

-   -   a) providing an osteoporotic patient having a functional spinal        unit comprising i) an upper vertebral body, ii) a lower        vertebral body and iii) an intervertebral disc therebetween,    -   b) inserting a device adapted to deliver an effective amount of        a bone growth agent into at least one of the vertebral bodies,    -   c) removing at least a portion of the intervertebral disc to        create a disc space, and    -   d) inserting a spinal implant into the disc space.

In some embodiments the device of the present invention is inserted intothe adjacent vertebrae prior to the disc replacement surgery. In someembodiments, the insertion of the device of the present invention isinserted into the adjacent vertebrae about one to about twelve monthsprior to the disc replacement surgery, for example, between about oneand about six months, e.g., between about three and about six months.

In one embodiment, the device is adapted to deliver an effective amountof an anti-resorptive agent as well. In one embodiment, the device isadapted to deliver the agent or agents into both of the vertebralbodies.

In some embodiments, the implant is a fusion cage. In others, it is amotion disc. The motion disc is preferably selected from the groupconsisting of a cushion disc and an articulating disc. In someembodiments, the articulating disc comprises

-   -   a) a first prosthetic vertebral endplate comprising:        -   i) an outer surface adapted to mate with a vertebral body            and        -   ii) an inner surface comprising a first articulation surface            suitable for supporting articulation motion; and    -   b) a second prosthetic vertebral endplate comprising:        -   i) an outer surface adapted to mate with a vertebral body            and        -   ii) an inner surface comprising a second articulation            surface suitable for supporting articulation motion.

In some embodiments, the motion disc is a two-piece design (wherein thearticulation surfaces of the prosthetic endplates are adapted to form anarticulation interface). In others, the motion disc is a three-piecedesign further including a core (wherein opposed articulation surfacesof the core are adapted to form two articulation interfaces with thecorresponding articulation surfaces of the prosthetic endplates).Likewise, the implant of the present invention can be implanted into anosteoporotic or osteopenic hip or knee prior to replacement thereof witha prosthetic hip or knee.

In some embodiments, the spent osmotic pump can be removed by a devicecomprising a magnet.

In one embodiment (for example, as shown in FIG. 10), there is provideda drug delivery device having both a modular design and a dual drugdelivery capability. Accordingly, it has all the advantages of thedevices shown in earlier Figures, but with further advantages.

Now referring to FIG. 10, there is provided an osmotic pump implant 171for providing sustained delivery of at least two therapeutic drugs to abone, comprising:

-   -   a) a tubular member 173 having a proximal end portion 175, a        distal end portion 177 and a throughbore 179,    -   b) a semi-permeable membrane 181 located in the proximal end        portion of the tubular member,    -   c) a distal piston 183 provided in the tubular member, defining        an intermediate chamber 185 and a distal chamber 187,    -   d) a proximal piston 189 provided in the tubular member,        defining the intermediate chamber and a proximal chamber 191,    -   e) an osmotic engine 193 located in the proximal chamber, and    -   f) a first therapeutic drug 195 (preferably, a bone forming        agent) located in the distal chamber,    -   g) a second therapeutic drug 197 (preferably, an anti-resorptive        agent) located in the intermediate chamber.

In some embodiments, the carrier comprises a tubular member comprising:

-   -   i) a proximal end portion,    -   ii) a distal end portion, and    -   iii) a throughbore defining an outer surface and an inner        surface,        wherein the outer surface has a threadform thereon and the inner        surface is adapted for releasable engagement of the outer        surface of the osmotic pump.

In other embodiments, the formulation is delivered into the bone throughthe endplate of the vertebral body.

When a modular drug delivery device is selected, the system should bedesigned so that the drug pump is easily insertable into the carrier,remains in place during use and is easily removable.

In some embodiments (for example, as shown in FIG. 12), these attributesare achieved by providing a rubber annulus 199 upon the inner annulus ofthe drug pump bore.

When the drug pump must be replaced, the clinician is confronted withthe problem of finding the pump (whose proximal end is located a fewcentimeters below the skin surface) and redamaging soft tissue overlyingthe pump. Accordingly, in some embodiments, and now referring to FIG.11, the carrier is provided with a proximal transmuscular tube 200located proximal to its threaded portion and in fluid communication withthe throughbore. Because the tube extends essentially all the way to theskin surface, the clinician will now be able to locate the device withrelative ease. In addition, the clinician no longer needs to re-damagethe soft tissue lying between the skin and the target bone. In someembodiments, the tube may be perforated with holes 202 for providingfluid access to the semi-permeable membranes of the osmotic pump.

Now referring to FIG. 11, in some embodiments, the proximal portion ofthe flexible tube is provided with a radio-opaque marker 201 (See FIG.14) so that its identification under fluroscopy is even easier. In otherembodiments, the radio-opaque marker(s) are replaced with LEDs.

In some patients, the osteoporosis may be so extensive that athreadform-based carrier may not provide a sufficient purchase into thebone, thereby producing implant instability. Accordingly, in someembodiments, the carrier comprises a helix.

Therefore, in accordance with the present invention, a drug deliveryimplant for providing sustained delivery of a therapeutic agent to abone is provided, comprising:

-   -   a) an osmotic pump having an outer surface and an exit port, and    -   b) a substantially helical carrier defining an inner recess,        wherein the osmotic pump is received within the inner recess.

Now referring to FIG. 12, in order to ease the insertion of the drugpump into the carrier and to mitigate any potential rubber wear issues,the distal end of the drug pump may be provided with a beveled nose 207or bulleted nose. Likewise, the carrier may be provided with a beveleddistal end 208 as well.

After the drug pump has dispensed the drug, it should be removed fromthe patient and replaced with a new one. However, since the pump hasbeen securely situated with the carrier, its removal may be problematic.Accordingly, in some embodiments, the drug pump is provided with removalmeans. In some embodiments, and still referring to FIG. 12, the removalmeans comprises a thread 209 provided upon the inner annulus of the drugpump. In some embodiments, the spent osmotic pump can have a removalthread 209 on its inner bore (as shown in FIG. 12), and be removed by adevice (not shown) having a complementary thread. During removal, theclinician inserts a screwdriver down the carrier tube and breaches theproximal semi-permeable membrane of the pump, thereby gaining access tothe pump bore. The screwdriver is fitted with a thread that mates withthe thread located upon the inner surface of the drug pump. Subsequentrotation of the screwdriver engages the pump to the screwdriver. Lastly,the clinician removes the screwdriver and the pump engaged thereto fromthe patient.

In other embodiments, the removal means can include a recess provided atthe distal end portion of the tube (modular hips).

Now referring to FIGS. 12 and 15, in some embodiments, the pump has aproximal laterally extending ridge 203, and the carrier has a ledge 205.Together, these features provide a stop that insures the drug pump isnot over-extended into the carrier. When a replacement drug pump isprovided in the carrier, it would be advantageous to insure the ultimatelocation of the pump vis-a-vis the carrier. Accordingly, in someembodiments, the drug pump is provided with a stop. In some embodiments,the stop comprises a lip extending radially from the outer surface ofthe proximal end portion of the pump. When the replacement pump isinserted into the carrier bore, the stop will seat upon a ledge formedupon the proximal end of the annulus, thereby insuring a fixed locationwithin the carrier.

In some embodiments, the barrel of the osmotic pump is made of atitanium alloy.

In some embodiments, the carrier is made of a titanium alloy orcarbon-fiber reinforced polymer, such as PEEK. Preferably, it is made ofa material having a stiffness relatively close to that of cancellousbone. Preferably, it is made of a material having a stiffness (i.e., amodulus of elasticity) of between about 0.1 and about 10 GPa.

In some embodiments, the exit port holes at the distal end portion ofthe osmotic pump are coated with a non-stick material, such as TEFLON®.It is believed that the TEFLON® will prevent bony ingrowth into the exitport holes from the bony tissue outside.

In some embodiments, the treatment is delivered by loading a hollowedout fracture fixation device or devices including a tubular bone screw,a tubular lag screw, and a fracture fixation plate. These devices can beeither metallic or non-metallic, and absorbable or non-absorbable. Asabove, these devices may also have two compartments: one loaded with abone forming agent and a second loaded with an anti-resorptive agent. Inanother embodiment, one compartment is loaded with the bone forming andanti-resorptive agents contained in bioabsorbable macro-spheres. Themacrosphere dissolution is tailored such that the bone forming agentsare released first followed by the release of the anti-resorptive agent.In some embodiments, the macro-spheres are constructed such that bothdrugs are released simultaneously.

Now referring to FIG. 17a, there is provided a cannulated lag screwadapted to deliver bone-forming and anti-resorptive agents to a fracturesite in the bone. The lag screw 201 of the present invention comprises:

-   -   a) a tubular portion 203 containing a bore 205 and an outside        surface 207,    -   b) a threaded portion 209 located upon a proximal portion 211 of        the outside surface,    -   c) a plurality of holes 217 connecting the bore and the outside        surface, and    -   d) a stop 213 located upon a distal portion 215 of the outside        surface.

As with conventional lag screws, when the threaded distal portion of thetubular portion is advanced beyond the fracture and the stop begins toabut the bone surface, the lag screw acts as a vise to close thefracture.

In one embodiment, the bore 205 of FIG. 17a is filled with a firstplurality of macrospheres containing a bone forming agent (such as MP-52BMP14), and a second plurality of macrospheres containing ananti-resorptive agent (such as infliximab). MP-52 is described in detailin PCT Publication No. WO 93/16099 (Neidhardt), the entire contents ofwhich are incorporated herein by reference in their entirety. Themacrospheres are designed so that the bone-forming agent is released inabout the first month, and the anti-resorptive agent is releasedthereafter.

In the embodiment of FIG. 17b, the bore contains an osmotic drug pump231 containing a bone forming agent (such as MP52), and ananti-resorptive agent (such as infliximab). The pump is designed so thatthe bone-forming agent is released in about the first month, and theanti-resorptive agent is released thereafter.

Although the devices of the present invention are well suited fortreating osteoporosis, these devices may also be used to treat otherpathologies, including cancer tumors located in bones. For example, thedevice of FIG. 7 may be adapted to locally deliver an anti-cancer drugto a tumor located in a bone by simply replacing the anti-resorptiveagent with an anti-cancer drug. The dual delivery device of FIG. 8 maybe used if the cancer has caused osteoporosis as well. The modulardevice of FIG. 9 may be used if it is believed the patient may benefitfrom a long term treatment requiring replacement of a spent device witha new device.

In some embodiments, the distal end of the device is located at or nearthe tumor. In other embodiments, the distal end of the device is locatedat or near the region (i.e., volume) formerly occupied by a tumor.

The present inventors believe that OP can be more effectively preventedthan treated. Prevention is more likely to be the most-cost effectiveapproach, considering the enormous cost and morbidity of OP relatedcomplications. It would be desirable to achieve as high a peak bonedensity as possible prior to skeletal maturation. This could beaccomplished by considering estrogen injections at menopause for highrisk patients. These risk factors include small stature, sedentary lifestyle, post-menopausal caucasian women having a lifelong history ofcalcium deficiency. Other factors include genetic factors, alcoholism,and byparathyroidism.

EXEMPLIFICATION Example 1

This non-limiting prophetic example describes how to intraosseouslyadminister a first formulation comprising a bone-forming agent and asecond formulation comprising a HSCA (an anti-resorptive agent) into anuncoupled resorbing bone.

First, a clinician uses a diagnostic test to verify that a bone within apatient is osteoporotic.

Next, the clinician provides a local anesthetic (such as 5 ml lidocaine)to the region dorsal to the vertebral body to reduce subcutaneous pain.

Next, the clinician punctures the skin of the patient dorsal to the OPbone with a relatively large (e.g., 18-19 gauge) needle having a stylettherein, and advances the needle through subcutaneous fat and dorsalsacrolumbar ligament and muscles to the outer edge of the pedicle, andfinally punctures the cortical wall of the uncoupled resorbing bone.

Next, the stylet is removed from the needle.

Next, the clinician receives a drug delivery device of FIG. 9, in whichan osmotic drug pump having a smaller outer surface is adapted to fitwithin the larger bore of the carrier. This outer surface of the drugpump is about 4 mm in diameter. The barrel of the drug pump containsfirst and second formulations of the present invention.

The first formulation contains an effective amount of bFGF (basicfibroblast growth factor), while the second formulation containsREMICADE® infliximab, and has an infliximab concentration of betweenabout 0.4 mg/ml and about 4 mg/ml.

Next, the physician advances the device co-axially through the cannulaand screwed into the cortical wall of the bone. Water enters thesemi-permeable membrane of the device, eventually causes the expulsionof the first and then the second formulation into the OP bone.

Example II

This non-limiting prophetic example describes how to intraosseouslyadminister a formulation comprising a HSCA (an anti-resorptive agent)and saline into an uncoupled resorbing bone.

First, a clinician uses a diagnostic test to verify that a bone within apatient has high levels of a particular pro-inflammatory cytokine.

Next, the clinician provides a local anesthetic (such as 5 ml lidocaine)to the region dorsal to the vertebral body to reduce subcutaneous pain.

Next, the clinician punctures the skin of the patient dorsal to the bonewith a relatively large (e.g., 18-19 gauge) needle having a stylettherein, and advances the needle through subcutaneous fat and dorsalsacrolumbar ligament and muscles to the outer edge of the bone, andfinally punctures the cortical wall of the uncoupled resorbing bone.

Next, the stylet is removed from the needle.

Next, the clinician receives a syringe having a smaller gauge needleadapted to fit within the larger gauge needle. This needle is typicallya 22 or 24 gauge needle. The barrel of the syringe contains aformulation of the present invention.

The formulation contains REMICADE® infliximab, and has an infliximabconcentration of between about 0.4 mg/ml and about 4 mg/ml.

Next, the clinician advances the smaller needle co-axially through thelarger needle and past the distal end of the larger needle and past thecortical wall of the bone. The smaller needle is then further advancedinto the center of the cancellous portion. Finally, the cliniciandepresses the plunger of the syringe, thereby injecting between about0.1 and 1 ml of the formulation into the OP bone.

Example III

This non-limiting prophetic example is substantially similar to that ofExample II, except that the formulation comprises a depot-type sustainedrelease device comprising the co-polymer poly-DL-lactide-co-glycolide(PLG). The formulation contains infliximab as the antagonist, and has aninfliximab concentration of between about 30 mg/ml and about 60 mg/ml.

Example IV

This non-limiting prophetic example describes how to administerintraosseously a formulation comprising a bone forming agent (BFA) andan anti-resorptive agent (ARA) into an uncoupled resorbing bone.

First, a clinician uses a diagnostic test to verify that a bone within apatient has high levels of a particular pro-inflammatory cytokine.

Next, the clinician provides a local anesthetic (such as 5 ml lidocaine)to the region dorsal to the vertebral body to reduce subcutaneous pain.

Next, the clinician punctures the skin of the patient dorsal to the bonewith a relatively large (e.g., 18-19 gauge) needle having a stylettherein, and advances the needle through subcutaneous fat and dorsalsacrolumbar ligament and muscles to the outer edge of the bone, andfinally punctures the cortical wall of the uncoupled resorbing bone.

Next, the stylet and needle are advanced about 7 mm, and then removedthereby leaving a tubular recess in the bone.

Next, now referring to FIG. 16A, a threaded carrier having an innerthroughbore and a plurality of exit holes is inserted into the recess byscrewing the thread form into the tubular recess.

Now referring to FIG. 16B, a cannula is inserted into the throughbore.

Now referring to FIG. 16C, a flowable particulate bone forming agent(BFA) such as hydroxyapatite is flowed into the proximal end of thecannula. The BFA exits through the exit holes and enters theosteoporotic bone.

Now referring to FIG. 16I), the cannula is removed.

Now referring to FIG. 16E, an osmotic drug pump is snugly placed intothe throughbore of the carrier. The drug pump contains a first distallylocated formulation comprising a second bone forming agent (such as aBMP or FGF) and a second proximally located formulation containing ananti-resorptive agent (ARA) such as REMICADE® infliximab, and has aninfliximab concentration of between about 0.4 mg/ml and about 4 mg/ml.

As water infiltrates the semi-permeable membrane of the osmotic pump,the osmotic engine expands thereby, forcing each formulation distally.The first bone forming agent exits through each of the three distalholes. When the distal piston reaches the distal end of the throughboreand blocks the central exit hole, the ARA exits the throughbore throughthe remaining two lateral holes.

While this invention has been particularly shown and described withreferences to preferred embodiments thereof, it will be understood bythose skilled in the art that various changes in form and details may bemade therein without departing from the scope of the inventionencompassed by the appended claims.

What is claimed is:
 1. A method of therapeutically treating an uncoupledresorbing bone in a patient, comprising the steps of: a) administeringan effective amount of a first formulation comprising a bone formingagent into the cancellous or cortical portion of the uncoupled resorbingbone, and b) administering an effective amount of a second formulationcomprising an anti-resorptive agent in a sustained release form into thecancellous or cortical portion of the uncoupled resorbing bone, whereinthe anti-resorptive agent is a highly specific cytokine antagonistcomprising REMICADE® infliximab and wherein an effective amount of theanti-resorptive agent remains within the bone for at least one monthafter administration of the second formulation.
 2. The method of claim 1wherein the bone is non-fractured.
 3. The method of claim 1 wherein theamount of the first formulation comprising the bone forming agent iseffective to increase the density of the bone.
 4. The method of claim 1wherein the patient is post-menopausal.
 5. The method of claim 1 whereinthe uncoupled resorbing bone is a vertebral body.
 6. The method of claim1 wherein the uncoupled resorbing bone is a vertebral body and isadjacent to a fractured vertebral body.
 7. The method of claim 1 whereinthe uncoupled resorbing bone is a hip bone.
 8. A method of treatingosteoporosis in a patient, comprising administering an effective amountof a sustained release formulation comprising an effective amount of ahighly specific cytokine antagonist into the cancellous or corticalportion of at least one uncoupled resorbing bone, wherein the highlyspecific cytokine antagonist comprises REMICADE® infliximab and whereinan effective amount of the highly specific cytokine antagonist remainswithin the bone for at least one month after administration of theformulation.
 9. The method of claim 8 wherein at least one bone intowhich the formulation is administered is non-fractured.
 10. The methodof claim 8 wherein the amount is effective to increase the bone mineraldensity of the bone.
 11. The method of claim 8 wherein the patient ispost-menopausal.
 12. The method of claim 8 wherein the bone is avertebral body.
 13. The method of claim 8 wherein the uncoupledresorbing bone is a vertebral body and is adjacent to a fracturedvertebral body.
 14. The method of claim 8 wherein the bone isosteoporotic.
 15. The method of claim 8 wherein the bone is a hip bone.16. A method of treating an osteoporotic patient having a spinal unitcomprising an upper vertebral body, a lower vertebral body, and anintervertebral disc therebetween, comprising: inserting a sustainedrelease device into at least one vertebral body adjacent to theintervertebral disc, wherein the device is adapted to deliver aneffective amount of a bone forming agent and an anti-resorptive agentinto the cancellous or cortical portion of the vertebral body, and theanti-resorptive agent comprises REMICADE® infliximab and wherein aneffective amount of the bone forming agent and anti-resorptive agentremains within the bone for at least one month after administration. 17.A method of therapeutically treating an uncoupled resorbing bone in apatient, comprising administering an effective amount of a sustainedrelease formulation comprising an anti-resorptive agent into thecancellous or cortical portion of the uncoupled resorbing bone, whereinthe bone is nontumorous and wherein the anti-resorptive agent is ahighly specific cytokine antagonist comprising REMICADE® infliximab andwherein an effective amount of the anti-resorptive agent remains withinthe bone for at least one month after administration of the formulation.18. A method of therapeutically treating an uncoupled resorbing bone ina patient, comprising the steps of: a) administering an effective amountof a first formulation comprising a bone forming agent into thecancellous or cortical portion of the uncoupled resorbing bone, and b)administering an effective amount of a second formulation comprising ananti-resorptive agent in a sustained release form into the cancellous orcortical portion of the uncoupled resorbing bone, wherein theanti-resorptive agent is a highly specific cytokine antagonistcomprising REMICADE® infliximab, wherein the second formulation remainsin the bone in an effective amount for at least one month.
 19. Themethod of claim 1, wherein the bone forming agent is released from asustained release device.
 20. The method of claim 1, wherein theuncoupled resorbing bone is osteoporotic or osteopenic.
 21. The methodof claim 8 wherein the anti-resorptive agent remains in the bone in aneffective amount for at least two months.
 22. The method of claim 16wherein the device is adapted to deliver the bone forming agent and theanti-resorptive agent into the vertebral body for at least two months.23. The method of claim 17 wherein the anti-resorptive agent remains inthe bone in an effective amount for at least two months.
 24. A method oftreating a patient having a spinal condition, the method comprising:administering a first treatment of a pain-relieving therapy for a firstperiod of time from a first plurality of locations at a vertebra of thepatient; and administering a second treatment of the pain-relievingtherapy for a second period of time from a second plurality of locationsat the vertebra of the patient, wherein the first plurality of locationsis greater in number than the second plurality of locations, wherein theadministering of the first and second treatments is of a common modalityof delivery.
 25. The method of claim 24, wherein the first and secondplurality of locations have at least one location in common.
 26. Themethod of claim 24, further comprising sensing with a sensor a conditionpredicate to administering the first treatment, the second treatment, ora combination thereof.
 27. The method of claim 26, wherein the sensor isa biosensor.
 28. The method of claim 24, wherein an implant implanted inthe patient administers the first and second treatments.
 29. The methodof claim 28, wherein the implant includes a first component and a secondcomponent, and wherein administering the first treatment includesstimulating tissue of the patient at the vertebra of the patient in atleast one of an axial direction relative to the first and secondcomponents and a radial direction relative to the first and secondcomponents.
 30. The method of claim 28, wherein the implant includes afirst component and a second component, and wherein administering thefirst treatment includes stimulating tissue of the patient at thevertebra of the patient in both an axial direction relative to the firstand second components and a radial direction relative to the first andsecond components.
 31. The method of claim 28, wherein the implantincludes a first component and a second component, and whereinadministering the second treatment therapy includes stimulating tissueof the patient at the vertebra of the patient in a radial directionrelative to the first and second components.
 32. The method of claim 28,wherein at least a portion of the implant is implanted in a vertebralbody of the patient.
 33. The method of claim 28, wherein at least aportion of the implant is implanted at a location adjacent to avertebral body of the patient.